Laserfiche WebLink
,f:5 V� County <br /> / f.= s Safety and Buildings Division Dane <br /> :3t°.Q`''' /; 201 W.Washington Ave..P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> 'a SP'"�iI Madison,WI 53707-7162 <br /> i` 15-2DA0-0605 ,, <br /> Sanitary Permit Application Stele Transaction Number <br /> In accordance with SPS 38321(2),Wis.Adm.Code,submission of this form Is the appropriate governmental unit <br /> is required prior to obtaining a sanitary permit.Nolet Application forms for slain-owned P01VTS are submitted to Project Address(if different than mailing oddness) <br /> the Deportment of Safety and Professional Scevies. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Slats. Hwy 92 <br /> 1.Application Information-Please Print All Information <br /> Property Owner's Name Parcel d <br /> ,• <br /> ter,, Trever&Christen Otto 0507-111-80104 <br /> Property Owner's Mailing Address Properly Location <br /> 408 Azurene Lane Govt.Lot <br /> City,Slate Zip Code Phone Number " <br /> NE ,A, NE Id,Section 11 <br /> Verona,WI (circle one) <br /> 11.Type of Building(cheek all that apply) Lot it T 5 N; R 7 E a 1V <br /> ID I or 2 Family Dwelling-Number of Bedrooms 1 <br /> Subdivision None <br /> Block 11 <br /> ❑Public/Commercial-Describe Use <br /> 0 City of <br /> El Stow Owned-DacrlbeUx. <br /> CSM Number ❑Village of <br /> 9229 t Town or Primrose <br /> IIL Type of Permit: (Check only one box on line A.Complete line B if applicable) <br /> A- ®New System ❑Replacement System ❑TreatmentAiolding Tank Replacement Only ❑Other Modification to Existing System(=plain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber OP it Transfer to Now List Previous Permit.Number sad Date Issued <br /> Before Expiration Owner <br /> IV.Type of POiVTS Systetn/Component/Deviee (Check all that apply) <br /> ❑Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ®Mound s 24 in.of suitable soil ❑Mound a 24 in.of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Coniponmt lesptoin) ❑iretreaanent Device(esplein) <br /> V.Dlsperunl/Treatment Area lnformntion: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsl). Dispersal Area�Required(sl) Dispersal`A,eonn i'roposed(sP) System Elevation <br /> 450 ,y.6 C'.(, _ a„5 '7`�z�; 4,504'!,r/#`{�' 100.5' <br /> VI.Tank Info Capacity in Petal Nor Maelanurer <br /> Gollans Gallons Units ,R <br /> New Tanks ruisdns Tanks c 3 t , 1 ig <br /> L V 47, w E:O a <br /> Septic or tlsWi g Task 1000 1000 1 Crest x , <br /> Dashes Chamber 600 . 600 1 Crest x <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for Installation of the POWTS shuts on the attached plans <br /> Plumber's Name(Print) Plumbers S...: MP/MPRS Number Business Phone Number <br /> / <br /> Plumber's Address(Street CO,Sale.Zip Code) <br /> iC, Ca I4. r .,,, t.41 V ( ,� _, t r}L--- f•.._ _Y4' <br /> V111. unty/Department Us Only i /� <br /> ..proved ❑Disapproved <br /> Penult FL�f�i( ,Date Issued <br /> / Isw,lfig At%�.SiBatxarei� <br /> I ❑Owner Given Reason for Denial 1 L �3{j / „-'•.', .� - "t <br /> IX.Conditions of Approval/Reasons for Disapproval " I <br /> i. <br /> Attach to nrmplele plans far list system aaa submit to Ike County was as paper out Its than s:a s 11 Inches In slue <br /> SBD•6398(R.I I/1 I) <br />