Laserfiche WebLink
County <br /> Safety and Buildings Division <br /> Ave Washington <br /> 1400 E <br /> 2 �T i 9 Sanitary Permit Number(to be filled in by Co.) <br /> P.O.Box 71629 <br /> Madison,WI 53707-7162 <br /> Sanitary ]Permit ApplicationState Transaction Number <br /> n 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 Services. Personal information you provide may be used for secondary <br /> pin-poses in accordance with the Privacy Law,s.15.04(1)m,Stats. <br /> ' E. Application Information-IPlease print All Information <br /> ?ropsrty Owner's tame Parcel# 0•7 0,0 DW77 It <br /> t © .xvGv zr78 <br /> Property Owner's Mailin Address Property Location p <br /> s � 6 Rd GovL Lot <br /> vicy,State ZipCode Phone Number <br /> _ ^� / 44' %, Section_33 <br /> l r ex) t A).r y�7J 713 a,?® ®� (circle one <br /> 1L7e Type of Building(check all that apply) Lot# <br /> T'tg N; R_ E or N <br /> } 4 ar 2 Fann:ily Dwellb-ig-Number of Bedrooms Subdivision Name <br /> Block# <br /> '.Public/Comrnercial-Describe Use <br /> ❑City of <br /> CSM Number ❑ a '• <br /> J State Owned-Describe Use b Village of <br /> Town of <br /> Z:, yr e of rrmit: (Check only one boar on line A. Complete line B if applicable) <br /> 1 u 3?ew System ❑Replacement System Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> ?s• ❑ Permit Renewal I ❑ Permit Revision ❑ Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> :Before-Ixpiration Owner <br /> '! Z��e of POWT System/Component/Device: (Check all that apply) <br /> Non-Pzessur ized in-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> Hotdiing Tauk ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> U.Dispersal/7freatment Area Information: <br /> i �^esign Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(so Dispersal Area Proposed(so System Elevation <br /> i <br /> i ^r• antic Info Capacity in Total #of Manufacturer <br /> i L <br /> r Gallons Gallons Units L, o° ' y <br /> New Tanis Existing Tanks U <br /> Septic or wkfdhT1FMk <br /> j Dosing Cha;yber <br /> t <br /> 1 i11(il•lesponnsibility Statement- 1,the undersigned,assume responsibility for installation of the Pol shown on the attached plans. <br /> Plumber's Name{Print) Plumb 's Si ture MP/MPRS Number Business Phone Number <br /> ;si?�;E 2JFSHflLM 227691 <br /> t � 715-349-7286 <br /> t iunnber's Address(Street,City,State,Zip Code) <br /> E O BOX 514,SIREN,W1- 54872 <br /> VII!'.County/D artnnent Use Only <br /> �pprovcd ❑Disapproved Pcrnit Fee Date Issued Issuing AgC 111 ' gnature <br /> � ❑Owner Given Reason for Denial � 3�.5 ��Z/ �• <br /> CoUnditions of Appn ov21/Reasons for Disapproval <br /> D <br /> MAY 17 2021 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 /2 x 11 <br /> Ott ou <br /> SBLa-6398(Rd313) `And 84"I"S E)Vat ment <br /> Q ''3-75 <br />