Laserfiche WebLink
I <br /> `,"Arukv'� County <br /> %g' - Safety and Buildings Division Od er� t3 1 <br /> 201 W.Washington Ave., P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) ! <br /> �\ p$ 1') Madison,WI 53707-7162 <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 Servies. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s.15.04(l)(m),Stats. <br /> I. Application Information-Please Print All Information al 1/' - J <br /> Property Owner's Name Par. <br /> /21 /J. n 0 1 - — 4700 G <br /> Prope Owner's Mailing Ad.Tess Property Location <br /> 7G( maple j2f t Ue. Govt.Lot <br /> City,State Zip Code Phone Number 1,---SE '/a, 3E A Section .- 3 <br /> 07t Ho h 2 (circle one) <br /> �P T Le N; R 7 EorW <br /> II.Type of Building(check all that app i Lot# <br /> t�l or 2 Family Dwelling-Nu of Be •ms ✓ / Subdivision Name <br /> ____./-- Block# <br /> ❑Public/Commercial-Describe Use _ <br /> ❑City of <br /> ❑State Owned-Describe Use CSM (0 5 1 ❑Village of a <br /> B Town of S etrp 610 le <br /> IOSL S <br /> I ' J <br /> III.Type of Permit: (Check only one box on line A. Compl- e line B if applicable) <br /> A. 13 New System ❑Replacement System ❑Treat ent/Holding Tank Repla nt Only ri.Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner 1 <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> ❑Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade 6 Mound?24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) § <br /> V.DispersaUTreatment Area Information: <br /> Design Flow(gpd) Design SoipApplication Rate(gpdst) Distp2,1,Area Required(st) Dispersal Area Proposed(st) System Elevation <br /> 7 sf , G l.2 5-0 t/f 7 L/ /Of-, L <br /> VI.Tank Info Capacity in Total #of Manufacturer _ <br /> Gallons Gallons Units A ( 1' <br /> New Tanks Existing Tanks `pgg c 8 g li <br /> oc V rn m 0 ii.o n. <br /> Septic or Holding Tank i' <br /> /65-0 /65-0 / Ai Pad 4 <br /> Dosing Chamber /t7 6 U /DO a / /12 r w.,, a <br /> VII.Responsibility Statement- I,the undersigned,assumesp'■ Ibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plu r s Sign (-----.-- MP/MPRS Number <br /> STEVEN R. CROSBY .../' 227009 608-849-8771 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 7361 DARLIN DRIVE, DANE, WI 53529 <br /> ) <br /> VIII.County/Department Use Only <br /> ' proved ❑ Disapproved I / � <br /> r \ ❑Owner Given Reason for Denial �� /7 i //, -. ♦ �` <br /> .. <br /> IX.Conditions of ApprovaUReasons for Disapproval c-''.'. `-, <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 its s I I inches in size <br /> SBD-6398(R. t l/i l) <br />