Laserfiche WebLink
Coun <br /> Safety and Buildings Division <br /> i OS ? 201 W.Washington Ave P.O. BOX 7162 Sanitary Permit Number(to be filled in by Co.) <br /> P$ u Madison,WI 53707-7162 W <br /> 9hx@IUN xk .55 V V Z6 Z <br /> Sanitary Permit Application State Tra action Number <br /> In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental VI <br /> unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are Project Address(if different than mailing address) <br /> submitted to the Department or Safety and Professional Servies. Personal information you provide may be used S P-I I <br /> for secondary purposes in accordance with the Privacy Law, s. 15.04 1 (nl). Stats. <br /> I. Application Information -Please Print All Information <br /> -1 <br /> Property Owner's Name r/L-�-- Parcelk07-J.32'2 41-15-0 -102-000-D/301, <br /> /7)m F /--4 � 0�k` � �J 32-S204- /- z(Do <br /> Property Owner's Ma fling Address Property Location <br /> 3 9 f�Q� r ��vr�• Govt. Lot <br /> City,State Zip Code Phone Number 4 <br /> CfJli{IIgZr�7ZL(j/IJIJ wi, 7i,1- Sam 320`7' (circle one) <br /> Il. Type of Building(check all that apply) Lot R T '�// N; R /s E or(0— <br /> �s <br /> P6 or 2 Family Dwelling-Number of Bedrooms Subdivision Name_ ea'� � ; Z <br /> Block q <br /> ❑Public/Commercial -Describe Use ❑ City of <br /> El State Owned- Describe Use <br /> CSM Number ❑ Village of <br /> V�P I&q AlAtt /✓F XTown of 'S c.,-3 L-S':-1 <br /> III. Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' KNew System y ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only [J Other Modification to Existing System(explain) <br /> B, ❑ Permit Renewal ❑ Permit Revision ❑ Change of ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IV. Type of POWTS S•stem/Com orient/Device: (Check all that apply) <br /> X,Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in.of suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain)_ _ ❑Pretreatment Device(explain)_ <br /> V. Dispersal/Treat teat Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(g)xlst) Dispersal Area Required(s0 Dispersal Area Proposed(sl) System Elevation <br /> 30O7 t7� 67 -134 c)8,0�? <br /> VI. Tank Into Capacity in • Total Aof Manufacturer <br /> Gallons Gallons Units o u u <br /> New Tanks Existing*ranks ,~ v u v a. <br /> v u ti 2 W U a <br /> Septic or Ilolding Tank -7�30 <br /> Dosing Chamber <br /> VII. Responsibility Statement- 1, the undersigned, assume responsibility for Installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Prin q Plum ria rare MP/MPRS Number Business Phone Number <br /> o hl ot�er ao7-4-0749 7�S��s��'SO <br /> Plumber's Address(Street . City.State, Zip Code) <br /> VII . Comtt /De arhnent Use Only <br /> Approved ❑ Disapproved Permit Fee Lr� Date Issued)n Issuing A nature [� /,kms <br /> ❑ Owner Given Reason lox Denial <br /> $ ,.5 2j Z 'e3 j %l e r vNlt�Z <br /> mna <br /> IX. Conditions of Approval/Reasons for Disapproval - <br /> a�oa s ti Jnr <br /> _ Q <br /> Attach u,complMr plw\e nor the eyxmau an—A snbmil w the Conn(y only un paper nut less Ilnm B Id x01 . <br /> es{n size <br /> SBD-6398 (R. 11/11) <br />