Laserfiche WebLink
County <br /> Industry Services Division 3 tA 0 h 1( <br /> 1400 E Washington Ave Sanitary Permit Number(to be tilled in by Co.) <br /> P.O. Box 7162 (� �Ig� <br /> Madison,WI 53707-7162 t'il v (, <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 W10'- I <br /> is required prior to obtaining a sanitary permit. Note:Application forms for state-owned POWTS are submitted to Project Address(if different than mailing address) <br /> the Department of Safety and Professional Servies. Personal information you provide may be used for secondary 51 oa <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Slats. /r,-e��-eN 120t, <br /> I. Application Information-Please Print All Information V <br /> Property Owner's Name^ Parcel# <br /> d'w0-ls <br /> Od'1. 01 0�30d0100 <br /> Property Owner's Mailing Address /� Property Location <br /> �. /3 77 t &.,I W ; 11 14M-f Or Govt.Lot <br /> City,State Zip Code Phone Number %, y, Section <br /> S t r b-� 8 y3 (circle one) <br /> II.Type of Building(check all that apply) Lot# T t o N; R E or® <br /> I or 2 Family Dwelling-Number of Bedrooms 3 Subdivision Name <br /> a <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of <br /> ([?Town of J�c,lc <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. New System ❑ Replacement System ❑Treatment(Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> won Pressuized In-Ground ❑ Pressurized In-Ground ❑ At,Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑ Holdma Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V Ds er'sal/Treatment Area Information: <br /> Deiigif`Ft`ow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(so Dispersal Area Proposed(st) System Elevation <br /> q_ro S-` 9 049 cl00 1 9 y,Y 4 o 976 <br /> VI.Tank Info Capacity in Total #of Manufacturer y <br /> Gallons Gallons Units �, o <br /> New Tanks Existing Tanks o <br /> cU my wU a <br /> Septic or Holding Tank /QrQ /Q,•f�� TH f'i ��ra ?�O�' <br /> Dosing Chamber.. <br /> VH.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWWS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> R/G�G G/., s I� �e��l�� 7/�Aloe' y/ <br /> D 7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 7 b0 wt <br /> 33— Gr1volosfr,, W -Vs.:r <br /> VIII.Coun /De artment Use Only <br /> pproved ❑ Disapproved Permit Fee Date sue suin A ent•Signa e <br /> ❑ Owner Given Reason for Denial <br /> $o.tab 9 IR "Iq _. <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> 4t iMof k 50 <br /> APPROVID ►.K4-oloo SEp 19 2019 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 In-x 1 inche Urngtt gUnty <br /> Land Servioas Department <br /> SBD-6398(R0313) w5 <br />