Laserfiche WebLink
.7..-,--`, sArvkiii,.. County <br /> r .' 'Sw. \..` Safety and Buildings Division " � <br /> nQ nE' <br /> js 0, S ' 11i, 201 W.Washington Ave., P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> PS )`.1 Madison,WI 53707-7162 <br /> if <br /> ' 4,rtuit•,� <br /> 13 - --Oca.S <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 info o y�P secondary <br /> purposes in accordance with the Privacy Law,s. 13.04(1)(m),Stats ( ���� <br /> I. Application Information-Please Print All Informatio ���++++ 0t,iq Ifalt <br /> Property,Owner's Name MAR 1. 2016 Parcel# <br /> lJ rod 6 i l So 4 rc0607 - 013- c15(15 - 6 <br /> Property Owner's Mailing Address Public Health MDC Property Location <br /> 5-6 0 e T! l Environmental Health Govt.Lot <br /> City,State n Cur Zip Code Phone Number �.iy;' /, y(.V /,, Section 5 <br /> ea e 4 e ti e l t4 --- 5 0 - t 0S)) 5-71- 5 ,29 (circle one) <br /> � T � N; R -7 E or W <br /> II.Type of Building(check all that I ly) of# <br /> �/ Subdivision Name <br /> ` <br /> l or 2 Family Dwelling-Number o :edrooms r /3 v°C-� <br /> Block# <br /> ❑Public/Commercial-Describe Use ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of Li Town of Ste. rtn Ck(.t <br /> h- <br /> i'''. <br /> r/i/1-1 `i <br /> _ <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' l.New System ❑ Replacement System ❑Treatment/Holding Tank Replacement Only CI Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑ Permit Revision <br /> ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> Er-Non-Pressurized[n-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 /> - <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(st) Dispersal Area Proposed(sf) System Elevation <br /> Lob ' , Co "/Ooo i-fau /co, Y /00. 0 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units <br /> P. o u <br /> New Tanks Existing Tanks w 2 u Ei v v " <br /> ` ., 0 8 4� <br /> l o.U y H on i..C7 n. <br /> („ Se r Holding Tank <br /> Dosing Chamber <br /> VII.Responsibility Statement- I,the undersigned,assu responsibility for installatio f the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plugsber'S`Si ature-7 MP/MPRS Number <br /> STEVEN R. CROSBY C' 227009 608-849-8771 <br /> Plumber's Address(Street,City,State,Zip Co <br /> 7361 DARLIN DRIVE, DANE, WI 53 29 <br /> VIII.County/Department Use Only ----- <br /> �,� Permit ee Date Issued uin Age . s , `� <br /> lXAnproved ❑ Disapproved $ / ` .\ <br /> ❑Owner Given Reason for Denial ,�� i ( / �- 4 <br /> IX.Conditions of ApprovalReasons for Disapproval / . - <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x it inches in size <br /> SBD-6398(R. I l/1 l) <br />