Laserfiche WebLink
County <br /> Safety and Buildings Division <br /> 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> tiSP$' g Madison,WI 53707-7162 <br /> 81?61 <br /> Sanitary Permit Application state Trat�aetiio umber <br /> In accordance with SPS 383.21(2),W is.Adm.Code,submission of this form to the appropriate govcmmenW unit (.gyp F (124.Jt Gn7 <br /> is required prior u;obtaining a sanitary permit. Note:Application forms for stNe-owned POWYS aresubmined to Project Address(if different than mailing address) <br /> the Department of Safety and Professional Servics. Personal information you provide rimy be used for secondary <br /> purposes in accordance with the Privacy Law,s. 15.04(1 xm),Stab. 6755-7`1Gl <br /> 1. Application Information—Please Print All Information <br /> Property Owner's Name i" Pereei# 020-4f314-0(o-SOO <br /> Eu6me old-'0l'i -07-(,?20-2 -I -505-006-0/4axo <br /> Property Owrrer's Mailing Ad - Property Location <br /> r iVe N Gr`n, lot <br /> City,Slate Zip Cade Phare Number Section <br /> /bVe 3 6 ,/ .�Z JIdL (circle on <br /> 11. PPY)pe of Building(check all that apply) Lor# V 4 T N; R �O E o <br /> I ort Family Dwelling-Number of Bedrooms Z Subdivision Name <br /> Block Is <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of <br /> C�9v8�i XT---r '*z <br /> 111.Type of Permit: (Check only one boa on line A. Complete Bae B if applicable) <br /> A_ ❑ New S stem <br /> y ❑ Replacement System [FTreatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑Change of Plumber ❑Permit Transfer to New L Prevr Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS S stem/Com onent/Device: (Check all that apply) <br /> ❑ Non-Pressurized In-Ground ❑ Pressurized in-Ground ❑ At-Grade ❑ Moun 1>_24 in.of suitablesoil ❑ Mound<24 in.of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dis ersalfTreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(st) Dispersal Area Proposed(sf) System Elevation <br /> VI.Tank Info Capacity in Taal #of Manufacturer <br /> Gallons Callas Units D o v <br /> New Tmrks Existing Tanks 'tO- e <br /> 6 U <br /> Septic or Holding Tank /� 2 / <br /> Dosing Chnnber <br /> VII.Responsibility Statement-1,the undersigucd,snow respoasibr'd' for installation of the POWTS shown on the attached plans. <br /> Plu is Name(Print) Plum i MP/MPRS Number Business Phone Number <br /> o er it-1 /� 7a <br /> Plumber's Address(Street,City,State,ZipC ) <br /> OW-'o -14/mi' epi lNeLS��w:s4�g <br /> VIII.County/Department Use Only <br /> O Approved ❑Disapproved Permit Feer r� Date IssuedL Lssuing A gnature <br /> El Owner Given Reason for Denial $ <br /> ` .2 'M7 2 �Cj` <br /> IX.Conditions of nApprovatUReasons for Disapproval WN LtIr <br /> .So;l MapINp1Galier 34{408�:61�E tlo«a.y g-- l <br /> 41-39C-r$39D : 6rYYGatl.t—r41wwGy►4.wp6G. �iCT 2 9, 2012 <br /> Attach to complete Pleas for the system and submit m the Cavity only un paper net Int than a In a Il MO ' TY <br /> CVOUN <br /> Bud ZONING f <br /> SBD-6398(R. 11/11) <br />