Laserfiche WebLink
-� <br /> -e%i i' tip County, ���y <br /> / r4 Industry Services Division t'J t-.V r►ell <br /> a,. f iry‘ <br /> ,4r ¢1„ 1400E Washington Ave Sanitary Permit Number(to be tilled in by Co.) <br /> '� ` 40 r1 P.O. Box 7162 �A � n,, <br /> ', $ r,i Madison, WI 53707-7162 3Kl�". 0-29 <br /> ai pi <br /> Sanitary Permit Application <br /> StateTransa//ctionNumber <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit 1,!/AA 18C, <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 <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. U �{N �� /� / <br /> I. Application Information-Please Print All Information Hayti-co y O� <br /> Property Owner's NameParcel# <br /> 07-oJ.o-d-yp_!6 -0 S- 3 0g- t,o o <br /> ./� <br /> 5114 re;i- LL.c. Qv,, rvu.^s 6,•isyyrou rtot -011000 tt <br /> Property Owner's/ MailingJAddres Property Location <br /> ) 66) 6 L ; /Il L, ke �nn l.d Govt.Lot $ 24 <br /> City,State I_ ' Zip <br /> UCode <br /> fw Phone Number y, y,, Section <br /> '�`� eiC1S71'dr' WI _P O ci3 -207,_s6 6+ oS-6 IN; (circle one) <br /> II.Type of Building(check all that apply) Lot# T y R /6 E or® <br /> 0 l or2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block# <br /> ©Public/Commercial-Describe Use SO IR V S;les <br /> ❑ City of <br /> CSM Number ❑ Village of <br /> ❑State Owned-Describe Use <br /> ® Town of O 1t/4 l at <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> New System 0 Replacement System 0 Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> B. CIPermit Renewal ❑Pennit Revision ❑ Change of Plumber <br /> ❑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 /> fillio-i1::PAilified In-Ground 0 Pressurized In-Ground ❑ At1Grade ❑ Mound>24 im of suitable soil 0 Mound<24 in.of suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> V:Dispersal/Treatment Area Information: <br /> Desie Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> AASo , 7 3114 301/6 . 9S.is—9.7S9.o� 93.S <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> v <br /> Gallons Gallons Units B o <br /> UY' <br /> New Tanks Existing Tanks o n KI K1w y _ aa.U cn ., ii u.0 <br /> Septic or Holding Tank 3000 of 00V ,coo0 a W t'e5er <br /> Dosing Chamber.. /A.5-0y /d cO 015&o q �� �I Y t - ., <br /> / A <br /> VU.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 /> R I-/c- f/a,�/�,h c / L1 /,// 0W-Y-5---1 7/5:- .6— //5 7 <br /> Plumber's Address(Street,City,State,Zip Code) \ <br /> VIII.County/Department Use Only <br /> Permit Fee Date ssu [ gent Signa <br /> ❑Apyroved 0 Disapproved Owner Given Reason for Denial $3g a:i l` 7°9'4) <br /> IX.Conditions of Approval/Reasons for Disapproval bl&-2,_9.2 <br /> All 4.( ; kr <br /> reiut WKrVI.'4S wo.si` be followed.. lueu edea seal ues puB <br /> �tlunoo ueuans <br /> k 01,0440 will lye 8 ve41 topitS or 4W3 ptrI4uF ops Wet 04 <br /> Mtn vNah.txdals r'tla+t t +o �toper vkaiw aH.C.G. , OM f ddV <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 r/2 s 1 chi n size <br /> I <br /> SBD-6398(R0313) EIn u O B10 3 <br />