Laserfiche WebLink
"'` Safety and Buildings Division County <br /> :o,A, Dane <br /> ja•/I \ •, 201 W.Washington Ave., P.O.Box 7162 <br /> If 1 D$ T Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> �`%: ps 4; t3-20tCo - tea <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with s. Comm. 83.21(2), Wis. Adm. Code, submission of this form to the appropriate <br /> governmental unit is required prior to obtaining a sanitary permit. Note: Application forms for state- Project Address(If different than mailing <br /> ownedPOWTS are submitted to the Department of Commerce. Personal information you provide may address) <br /> be,ApptiQBtleddlibf esePinaeoRI IL61U/WOMfatOfty Law,s.15.04f1X(m),Stats. _ <br /> Property Owner's N me Parcel# <br /> Ma ing r-PP( k► CON\P 050/0907-183-6143-0 <br /> Prop rty Owner's Mailing Address Property Location <br /> 2 0 )Ci.X_O-k. ViCkti Govt.Lot <br /> City, State r Zip Code `P_hone Number /� /� +V Section <br /> 1 Q, v SQt G I (t U!0 g-*3 ._V la,.13 (circle one) <br /> II.Type of Building(check all that apply) Lot# T N; R E or W <br /> 1 or 2 Family Dwelling-Number of Bedrooms 3 23 Subdivision Name <br /> Block# Blackhawk Fields <br /> Public/Commercial-Describe Use City of <br /> CSM Number Village of <br /> State Owned-Describe Use Town of Roxbury <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. New System Replacement Treatment/Holding Tank Replacement Only Ot • odification to Existing System <br /> System (e ■aln) <br /> Reconnect 1-0 y <br /> B. Permit Permit Revision Change of Permit Transfer to LI •revious Permit Number and Data Issued <br /> Renewal Before Plumber New Owner <br /> Expiration . <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> 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 Dispersal Area Re uired(sf) Dispersal Area Proposed System Elevation <br /> Rate(gpdsf) v.4,:11-g;„ r—, �y (so <br /> VI.Tank Info Capacity in Total #of IGlanufacturer 2 <br /> Gallons Gallon Units <br /> New Tanks Existing Tanks s 2 . . <br /> 1. 1 t7 to LL CO d <br /> Septic or Holding Tank <br /> Dosing Chamber <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> Brian Elsing <br /> 14—`"\/ 1005477 608-432-4687 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> E10257 Greimel Road, Baraboo,WI 53913 <br /> VIII.County/Department Use Only _ <br /> Approved Disapproved Permit Fee / Date Issued Issuing Age at a <br /> Owner Given Reason for $ '1 <br /> Denial, U{/p”/Zr g G,,,P <br /> SBD-6398(R. 10/11) <br />