Laserfiche WebLink
•odae*rcvos, County <br /> Safety.and.Buftdings Division 7 � <br /> r <br /> • ;�g '5 l 201 W:Washington AVe;',P.O.Box 7162 3 tary Permit Number(to be tilled in by Co.) <br /> K i Madison,WI 63707--7162 <br /> ,.,� 13-2d t a o3� <br /> Sanitary Permit Application State TransactlonNumber <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this Rant to the appropriate governmental unit <br /> - Is required prior to obtaining a sanitary permit Note•.Application.&stm� � tied b Project Address(if different than mailing address) <br /> the Department of Safety and Professional Service. Personal intbrmatl t b ndttry <br /> .u ...sea In accordance with the Pri • Law s.15.04 I,m State. <br /> L Application Information-Please Print All Information 2a' + <br /> Property Owo s Name (�Or o S Z� Parcel N - <br /> 1 &i1 Ind" f r a i"•i a f/ Public Health MDC Q W"- 3b 3 - a.r""F1 <br /> Property Owners Mailing Address Environmental )ieaith Property Location <br /> 3 J). ii 4)f me- 72- Govt.Lot <br /> City,SV Zip Code Phone Number S y« <br /> ��s �!4, Semite S G <br /> 1— r3 circle one <br /> II.Typo of uildingg(check k e that a [' tot q T / N; R •I!( ,$or one) <br /> Family Dwelling-Number of Bedrooms i Y b, Subdivision Name <br /> Block 0 ii r 4'3 4 <br /> 'A ) ' ire derzr. <br /> ❑Public./Commercial-Describe Use ❑City of <br /> ❑State Owned-Describe Use CM Number ❑Village of <br /> 44rown of Jul S•y!b) <br /> III.Type of Permit: (Check only one box on line A. Complete line B If applicable) <br /> A. <br /> I New System ❑Replacement System ❑Treatment/Holding Tank Replacement Only 0.Other Modification to Existing System!llii� - B ys (explain) <br /> i B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Betbre Expiration Owner <br /> IV.T .e of POWTS tem/Com.onont/Device: Check all that a <br /> • <br /> 'f; •n•Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grede ❑Mound p 24 in.of suitable soli ❑Mound<241n.of suitable soil <br /> • <br /> ❑Holding Tank ❑Other Dispersal Component(explain) . ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Plow(gpd) Design Soil Application Rate(gpdat) Dispersal Area Required(st) Dispersal Area Proposed(at) System PIenatlon r e <br /> (04 ' 0 r`Jf /.0-4,k, .S7e� 14,,1 -4,0 Qr•u <br /> VI,Tank Info Capac ty in Total N of Manutgoturer a <br /> Gallons Gallons Units �sqr <br /> New Tanks Wang Teaks I '6A 1i „a <br /> Septio.ertidthtgTank /a.- • ., Lam E21---. <br /> VII.Res.onsibility Statement-I,the undersigned,assume responsibility for installation of I•L'OWTS shown on the attached•lane. <br /> Plumber's Name(Print) • ( Plumber's' gn i-' — MP/MPRS Number 1 <br /> STEVEN R.CROSBY I ' .-.err 227009 <br /> 608-849-8771 <br /> Plumber's Address(Street.City,State,Zip Code) <br /> 7361 DARLIN DRIVE,DANE,WI 53529 <br /> VIII.Coun /De•artment Use Oat <br /> ❑Disapproved <br /> rA Permit/Foe/ Date Issued <br /> ❑Owner Olven Reason for Denial $y/( � /°--1 lall / <br /> slrl Al././A <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach to complete plane for the system and eabmlt to the County only an paper not lose than 8 to x 11'aches In else <br /> SHD•6398(R. 11/11) <br />