Laserfiche WebLink
Industry Services Division County <br /> 1400 E Washington Ave UP/VP.T' <br /> lil, B <br /> �.i S P.O.Box 7162 S itary Permit Number(to be filled in by Co.) <br /> p5 Madison,WI 53707 7162 <br /> � 3S/38 <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 Services.Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. n//I. A lication Information—Please Print All Information l e &4xiOV <br /> Property Owner's Name Parcel# <br /> of wJ ' <br /> Property Owner's Mailing Address Property Location <br /> j � Govt.Lot <br /> City,State Zip Code Phone Number t/4, %,, Section L6 <br /> I'. 1 •t 66`2 trcle on <br /> �+ ,V T 31 N; R E oV <br /> II.Type of Building(check all that apply) Lot# <br /> 1 or 2 family Dwelling—Number of Bedrooms Z, Subdivision Name <br /> Block# <br /> ❑Public/Commercial—Describe Use <br /> ❑City of <br /> ❑State Owned—Describe Use CSM Number ❑Village of <br /> Town of t!t�/ lJ <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> ❑New System ❑Replacement System 19 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 S stem/Com onent/Device: Check all that apply) <br /> (TNon-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.Dis ersunreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> Stan yzq yz� %6. <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o v <br /> New Tanks Existing Tanks <br /> et U CA ; ti Lz V CS. <br /> Scptic or Holding Tank <br /> Dosing Chamber •L <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plu cr's Name(Prrint) / Plumber's Si gna MP/MPRS Number Business Phone Number <br /> 10 70lV;WV <br /> Plumber's Address(Street,City,State,Zip Code) <br /> G eI Ao, ,4 l A tel kle65l-er U.- 5y069 <br /> VIII.County/ e artment Use Only <br /> Approved ❑ Disapproved Permit Fee Date Issued Issuing Agent'SF°ature <br /> ❑Owner Given Reason for Denial <br /> $ 3 zr FYI <br /> IX,Conditions of Approval/Reasons for Disapproval <br /> n F= C F= 0V = <br /> _J <br /> Attach to complete plans for the system and submit to the County only on paper not less than 81/2 111 Inche <br /> MAY 0 3 2021 10: <br /> urnett County <br /> SBD 6398(R.08/14) Land Services Department <br />