Laserfiche WebLink
' Coaoty <br /> lt+* `r1 Safety and&dldings Division Dane <br /> ,t ,�,*A 201 W.Washington t. i ve.,P.O.sB 7162 senior/Permit Number(to be Riled in by Co.) <br /> .;tom t 3 —20 i '- 66421 <br /> . <br /> Sanitary Permit Application Slatc Transaction Number <br /> lo accordance with SPS31132l(2).Wis.Adm.Coda,submission of tbiscams m the appropriate.governmental Unit <br /> s oOL prior o ob4 ki!pa a::nitro p,,;p- <br /> blotz Application Tows for state-owned POWISare submitted to Project Addmss(if Mama then mailing addicts) <br /> -the Depot Beet of Safety and rrofessbnd Semis. Personal infottmwlon you provide may be used for secondary <br /> purposes io aeeordmtm with the Privacy Law.s.1s odt l Nml,St.es. Bakken Road <br /> I.App Ucatioa.Inforiiattion—Please Print AR information _ <br /> rmperty.Oatees.Name # / ._---' <br /> . Tyler Marks — <br /> Property Onnwes Mailing Address <br /> 2329 Bedner Road Govt.Lot <br /> Cay;Siate ZtpCadc 'PhoneNumber NW v, NE Y..Section 10 <br /> Madison,WI --63719 T 6 N, 7 tdmiem <br /> U.Type of Building(check all that amity) �. Lot 1 <br /> ®I or2 Ratify Dwelling-Nutnberoilledrooms 4 Subdivision Name <br /> . J� 6locktt . 37 Acre Metes&Bounds Parcel <br /> 0 Public/Ortanerciai–'Describe use 0 City of • <br /> 13 Stile Owned-Omni=Use cSMwwubcr 0 Village of ... <br /> 4 -- IS Town or Springdale <br /> Ill.Type f Permit: (Check Dilly one box oo'itne A. Coayilete line B If applicable) <br /> A. New System 0 Replacement System ❑Treater cntlHokfingTmk Replacement Only ❑Ohba Modification to Edging System(explain) <br /> D. 0 Permit Renewal 0 Pooh Revision 0 Ma. of Plumber 0 Pere*Transfer to New List Previous Pewit Nttmbet and Date Issued <br /> r gr <br /> i <br /> Before Expiration Owner <br /> IV.Type orPOW S Sys tom/Cosaponent/Devlem (Cat all that apply) • <br /> 0 Non:Piessw and InXirwad 0 Pressurized l•Oround 0 At-Garde )(Mound_>24 in.orsuitai iesoil .O Mound<24-)n..ofsuitabksoil <br /> o Holdatesak O Oth r Dispersal Component.(esplain) + 0 Pretreatment Device(explain) <br /> V.DispersaVlreatmentArea lafariaation: _ <br /> Desigot.Fidw(gpd) Design Soil Appiieolioa Dispersal Area Required jst) Dispersal Area Proposed A System Elevation <br /> 600 „,s6'."0� fpg'.'�VS .;,, ,a�' j�5x7 115.0' <br /> VI.Tank Info Capacity.in Total #or Manufacturer <br /> Gallons o$ U <br /> N yi 2 I Nay y mks Eliding Tanks r. v u A E 0 E <br /> Sg4irat"NigI* - 1000/300 1300 1 Dalmaray x • <br /> oosinitamber 750 750 1 Dalmaray x <br /> VIL Rospoasibtlfty-Statement 1,the rmderslgaed,assame:rapon$IbWty for Iasta latlon.of the PORTS shown on the attached plans. <br /> Plumber's Name.(Print) `Plumber's Sigooturc NIP/MPRS Nwnber Business Phone Number <br /> i—it�o "\ 3'Selle.. n/-� 2P75 5 bog-�5/S -6 <br /> Plumber's Address(Street.CStyitata Zip Code) <br /> 133 o FN-1-6— RA . V€ c-o tin t 'J I' 53 5-93 . . . .. <br /> Vi1L County/DepartmentUse Only <br /> jAplavved 0 Pmnit Fee Dalu retard Issnlrtg _ <br /> S OwncrGiven Reason for Denial li IC 2-3-rs-'• <br /> / <br /> IL Conditions of Approval/Reasons for Disapprove J <br /> Attach la nmplcle puma fir the system and submit to the County oily on paper oat less than 8 tel s II Incites Is size <br /> &/‘ <br /> SBD-6398(R.11/11) <br />