Laserfiche WebLink
yt�E arq�rpR County <br /> . 1 p Industry Services Division �R <br /> 1400 E Washington Ave 1�� —�! <br /> P.O.Box 7162 •• •ry Permit Number(to be fi e. "• . <br /> t A4,,,,,,,... 1.=-7i : Madison,WI 53707-7162 <br /> L�x,y 1 6`,015 �cj�• <br /> Sanitary Permit Application ,. <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 <br /> the Department of Safety and Professional Services. Personal information you provide may be used for secondary Project Address(if different than mailing address) <br /> purposes in accordance with the Privacy Law,s.15.04(1 Xm),Stats. <br /> I. Application Information-Please Print All Information 2043 NQWKiKsDA <br /> Property Owner's Name <br /> Parcel# <br /> L-WS ebom petioi b 0(a10Z8/87/03 <br /> Property Owner's <br /> /?Mailing rAddress Property Location <br /> 404 S l]la'(T00- Pv . Govt.Lot <br /> City,State I Zip Code Phone Number Nw ''/s, IJ1 '''A, Section 2-8 <br /> C.*O S S p lOt rs , 02 5 3SZ 8 (circle one) <br /> T (p N ; RIO �or W <br /> II.Type of Building(check all that app,. Lot# <br /> isi l or 2 Family Dwelling-Number of B . .. Subdivision Name <br /> ❑Public/Commercial-Describe Use Block# <br /> ❑State Owned-Describe Use ❑ City of <br /> CSM Number 0 Village of <br /> ®Town of �IU1IN <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑New System ❑ Replacement System ystem ®Treatment/HoMieg Tank Replacement Only ❑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 99—b351- 4/z3 /99 <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> lI 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/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application ersal Area Required(st) Dispersal Area Proposed(sf) System Elevation <br /> ExiS'i1 it5734 Rath � I D q� 'a t � 61-1( T/Arc) I <br /> VI.Tank Info Capacity in <br /> Gallons Total #of Manufacturer ? u Uo <br /> Gallons Units c 3 b I <br /> New Tanks Existing Tanks J1 � V in w"C7 a <br /> Cry`s•or#elding Tank X. "` 1000 1 W O bsi OD ❑ ❑ ❑ ❑ <br /> is• g Chamber k (000 I to <br /> ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS own on the attached plans. <br /> P tuber's Name(Print) Pl ignature i MP/MPRS Number Business Phone Number <br /> -W- Loyd&a b. .v - ..,v-c..6..,--- Z2(.8sr- 668- (Ay- 33ry <br /> Plumber's Address(Street,City,State,Zip Code) <br /> q 114 Coy to k-it41 l.. S3s 0Y <br /> VIII.County/Department Use Only <br /> Approved ❑ Disapproved Permit Fee Date Issued Issuing/. t S..n. / �r / <br /> ❑Owner Given Reason for Denial $5T-n- <br /> ' I�— q-'7'�/.� r <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> NM MI t• <br /> _pp pproval a b.im�. <br /> f`14 s7x- 1.--071C 7AK�t pi�M0 Clih/+'uj:S - i" Af� ,�f..¢A �o <br /> h 'r-164-- f at re 7� ,- rotiY D ter. .rill�'749Le- At h' <br /> APR 0 61015 �� <br /> rERte(44,�„,� K AiY Co'V' �t7 ro 6)C(JA/,_ u• c '1171, MDC <br /> �y�'ll�� Attach to complete plans for the system and submit to the County only on paper not less than d t11g71VIpcRa{n shel�I Health <br /> SBD-6398(R03/14) <br />