Laserfiche WebLink
County <br /> ! :t Industry Services Division �- <br /> �4t 5. "i 1400 E Washington Ave Sanitary Permit Number(to be tilled in by Co.) <br /> P 51 P.O. Box 7162Q <br /> `.° Madison,WI 53707-7162 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit <br /> is required prior to obtaining a sanitary permit. Note:Application fors for state-owned POWTS are submitted to Project Address(if different than[nailing address) <br /> the Department of Safety and Professional Servies. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,S. 15.04(I)(m),Stats. -1 <br /> c1rr,7 <br /> L A lication Information—Please Print All Information N, ZI iE <br /> Property L- Owner's Name Parcel# <br /> y hJo 17 <br /> ��✓o✓he Dwa�j -, d/0000 <br /> Property Owner's Mailing Address Property Location <br /> 6L9 d ok �� �w t � S vµf 11 Govt.Lot <br /> City,State Zip Code Phone Number N(N y, /'t'r" y, Section <br /> S`�739 7�5� aha SS9 T YO N; R /(y c1Eo�ee, <br /> II.Type of Building(check all that apply) Lot# <br /> 1 or 2 Family Dwelling—Number of Bedrooms L Subdivision Name <br /> Chock# <br /> ❑Public/Commniercial—Describe Use <br /> ❑ City of <br /> ❑State Owned—Describe Use_ <br /> CSM Number ❑ Village of <br /> Town of <br /> IIT.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> ❑New System KReplaceinent System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑ Change or Plumber ❑Permit Transfer to New List Previous Penni[Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> ❑Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> X Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: _ <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(st) Dispersal Area Proposed(st) System Elevation <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o o <br /> X, <br /> New Tanks Existing Tanks V �` a •� <br /> U <br /> a. U <br /> Septic or Holding Tank d Q 3 60G <br /> Dosing Chamber <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> !G I L/C jt�/ooe� 41 h s J f1 - ajo­�57s—i lis-ada�affs <br /> Plumber's Address(Stree,City,State,Zip Code) <br /> -7 76 o he�„ YJ_ w eb.5 fed w�7' <S`ye 93 <br /> VIII.Cour /De artment Use Only <br /> Approved ❑ Disapproved Perlin Fec Date Issued / Issuing Agent Signalur <br /> 11 Owner Given Reason for Denial $�.l ��` O �g—'I CQ <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach to complete plans for the system and suhmit to the County only on paper not less than R in x 11 inches in size <br /> SBD-6398(R0313) <br />