Laserfiche WebLink
ff.. dt;'.3y County ^^ \ ...J <br /> �� Industry Services Division k r n X77" <br /> 'it` O� 1400 E Washington Ave <br /> ;$ , S ti•:; l' 9 Sanitary Permit Number(to be tilled in by Co.) <br /> �;s �j P.O. Box 7162 CJ „a/9 <br /> ,z Madison, WI 53707-7162 <br /> '� G57 -!942 g Z T37 <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 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 ?/001 V <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. <br /> I. Application Information-Please Print All Information j w e✓ Rod' <br /> Property Owner's Name Parcel# t.�/-/to-13-.S /5- <br /> O-7-o3•1.-d- <br /> ScoTf" 1�'�SLASftvie a yy - a170042 <br /> Property Owner's Mailing Address Property Location <br /> 'It <br /> of 3 30 E. V:(/4 12-ea1 9r. 328DJ <br /> Govt.Lot <br /> City,State <br /> / /� Zip Code Phone Number y, /, Section /.� <br /> 0✓ eq-1SG1 e 9d 867jcircleone) <br /> II.Type of Building(check all that apply) Lot# T y N; R I E or� <br /> 2f I or2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use • <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of <br /> 0 Town of .5.1-11/-5.-5. <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> ❑ New System Cg 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 /> LNon Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑ Floldm=Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dtspersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> 5'sno • ' Gel? Gso 93. o <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> di Gallons Gallons Units o-o <br /> 0 <br /> U Y ti New Tanks Existing Tanks w T, y <br /> a U tn grn a..u a. <br /> Septic or Holding Tank f O SQ /OrO x <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 NIP/MPRs Number Business Phone Number <br /> r727 c /Z- //s .ic, , .// /V 5 f_/ -7/s=e-a.—y%s-.7 <br /> Plumber's Address(Street, ity,State,Zip Code) <br /> 4 777 o 5' e fr- wr r1' 3 <br /> 1VVIIII.County/Department Use Only <br /> ttrstppproved ❑ Disapproved Permit Fee Date Issued Issuing Agent Signature <br /> $ <br /> ❑ Owner Given Reason for Denial 3 -- 1D �C- Z " <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> � �G V C <br /> k- ,4) iii ill SEP 3 0 2020 ' Lh <br /> / e 'Cmi74 G-thw� p/- .3 24 A T� 4-7 f LI i. 1 i_./ . <br /> Attach to complete plans for he system and submit to the County only on paper not less than 8 1/2 a'l l inch <br /> 'urnett County <br /> Land Services Department <br /> SBD-6393(R0313) (.6i E�1� *,-( 6'.9-9 <br />