Laserfiche WebLink
a votAEXp%,...0,./ Industry Services Division County 1 <br /> �`�i 1400 E Washington Ave [�.! <br /> 0! ' P.O.Box 7162�'�' � � Sanitary Permit Number(to be filled in by Co.) <br /> _' Madison,WI 53707-7162 /�/� <br /> �fb'``*-sm�M_ fi I �-'2xtc; .& .s5 <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),Stets. <br /> I. Application Information—Please Print All Information <br /> Pro <br /> max Owner's Name Parcel# <br /> Pe_Kikt-1 °1 1004,y- 44411-4-e0 p2 t o7 -/D3' /c9o:7 <br /> Property Owner's M li Address �..,, �.�- Property Location 6(// f ��—f"�K d� /iv`r 0 <br /> ►`� <br /> Govt.kot <br /> City,State Zap Code Phone Number 4(A Y , <br /> ` 'A, Section <br /> j <br /> V <br /> f �^ Ge K ( 2-6o �V✓L' T Sub on NNam; R e PrrciEe L)m <br /> LoBlock# # ") A'II.Type of Building(check all that apply <br /> Alor 2 Family Dwelling—Number of Bedroo <br /> ❑Public/Commercial—Describe Use A ' <br /> �/ 0 City of <br /> ❑State Owned—Describe Use <br /> CSM Number ❑Village of <br /> 01 L ( 6 .Town of ®�/m.gio <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' ❑New System ❑Replacement System ❑Treatment/Holding Tank Replacement Only O/�j��r Modification to em(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 �d .- G-q-, 3 IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> ❑Non-Pressurized In-Ground ❑Pressurized In-Ground N At-Grade ❑Mound>24 in.of suitable soil ❑Mound c 24 in.of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil App'cation Rate(gpds f) Dispersal Area quired(sf) Dispersal Area Proposed(sf) System Elevation <br /> VI.Tank Info Capacity in Total #of Manufacturer , <br /> New Tanks <br /> Gallons Tanks Gallons Units A 1 it r �� <br /> Septic or Holding Tank _`.3 b 00 L'rj/on �� �i of <br /> Dosing Chamber �/1/a70 ✓lam"' 1 I /"1`=-e'11ti'- <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Niber's Name t) Plum sSignature -lf1P/ bey Business Phone Number <br /> Ko Ll <br /> I'`Iokt60)6 /' 4, J% p'.c6 6 (f 6 `"e1,7 `5365 <br /> Plumber's Address(Street,City,State,Zip Code) /� <br /> s _ -414 4 '40 !� 4 1/11e) 101 j : .7 <br /> .Conn /Department Use Only tyi <br /> 211:1 Approved ❑Disapproved <br /> Pernik F! 6�(i Ig� gAgent <br /> ❑Owner Given Reason for Denial Ss"/S 7 / <br /> I%.Conditio of Approval/Reasons for Disapproval <br /> ff sus 1-124.-.....0-5 ri e. __420 l 6 to t, ,...(0 0 . .4 <br /> tor-ca Le Cc•,..Pit_at- ...... <br /> Attach to complete plans fey the system and submit to the County only en paper not less than 81/1 z 11 inches in size <br /> 13D-6398(R.08/14) <br />