Laserfiche WebLink
/,--,:,i-; ,', County <br /> ''',f3;.% Industry Services Division /)t.1 r .— <br /> .ter, : .::;; .,- '. 1400 E Washington Ave Sanitary Permit Number(to be tilled in by Co.) <br /> : Yil <br /> P.O. Box 7162 SA-t lYAb_.23c <br /> 4,_ tai. ,". Madison,WI 53707-7162 q <br /> .Zv-�98�2 133 <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 /> iss 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 infonnation you provide may be used for secondary <br /> /1713 <br /> purposes in accordance with the Privacy Law,s.15.04(l)(m),Stats. <br /> I. Application Information-Please Print All Information Co Rd g- <br /> Property Owner's Name �rcel# .,d_y-_!y-df <br /> �crt Art_S©$- O a y <br /> jet. Net,-+,Neve 0 3!!000 <br /> Property Owner's Mailing Address Property Location <br /> 1- EliZA.6e.'k G� 'fi$ • <br /> Govt.Lot y <br /> City,State Zip Code Phone Number y, /,, Section y <br /> Ot,j P/4.0 is /4 60O/e (circle one) <br /> IL Type of Building(check all that apply) Lot 4 T 4/0 N; R /f1 E or� <br /> 4 I or2 Family Dwelling-Number of Bedrooms zi d Subdivision Name <br /> Block 4 <br /> 0 Public/Commercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use <br /> CSM Number Village of <br /> Il! Town of f e.7`*' <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> 0 New System fit Replacement System 0 Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Owner - <br /> IV.Type of POVVTSSystem/Component/Device: (Check all that apply) <br /> Fit N n P esst sized In-Ground ❑ Pressurized In-Ground 0 At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑ Ffoldm=Tank 0 Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V Dispersal/Treatment Area Information: ' <br /> Desigi Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(st) Dispersal Area Proposed(st) System Elevation <br /> VI.Tank�n o s Capacity in l�ota� #of Man fO 0Fg r v S-1 90.o/9P• <br /> Gallons Gallons Units o - B <br /> New Tanks Existing Tanks ' v S' y 2 2 <br /> cU Ci•) rn u.0 a. <br /> Septic or Holding Tank 1 fe) AroMI <br /> Dosing Chamber.. 7.fo • 770 M f Eallil <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 /> /2/Gk--- //0 /c/,. r jae /%. <74600—ii—/ ,<C7- f6f-y4s7 <br /> Plumber's Address(Street,Crity,State,Zip Code) <br /> o ,- ? -'- x/ .- i --3- f <br /> VIII.County Depar ment Use Only / <br /> Approved ❑ Disapproved Permit Fee Date Issued Issuing Agent Signature <br /> 0 Owner Given Reason for Denial 373 J O ' t!G' 2-D h./. /r :Nf- rf U �\ v/ L <br /> IX.Conditions of Approval/Reasons for Disapproval --. <br /> OCT 0 9 2020 <br /> BURNFTT t^lajt TY <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 I/:x 11 inches in six20NING <br /> - eoci2Z.o S Y.25 <br /> SBD-6398(R0313) <br />