Laserfiche WebLink
,,�aarr`yr�. County ,�yy� <br /> °, Safety and Buildings Division J' <br /> fl=,'gip \;:, <br /> / S �� �� 201 W.Washington Ave., P.O. Box 7162 Sanitary PermitNumber(to be filled in by Co.) <br /> q. P F Madison,WI 53707-7162 <br /> I3 2016 - OO/I <I <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 333.21(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(1)(m),Stats. C C E I V E D <br /> I. Application Information-Please Print All Information RE Q� /'e.5°K ad a <br /> Property Owner's Name Parcel# <br /> (7e rat& d- 149 )c(551' )E' ' MAY 112016 vO6i0 - 3R - 9/0F - 3 <br /> Property Owner's Mailing AddYess Property Location <br /> Public Health MDC <br /> 0 i Lv ie r OCtd U;a�J ' Environmental Health Govt.Lot <br /> City,State J Zip Code Phone Number 1/4 , <br /> .z <br /> , Nlv /, Section 3 <br /> fb h ;Lori LU.L 5.-3 rTs (circle one) <br /> II.Type ' Building(check all that ply 2 Lot# <br /> T [!c N; R �O EorW <br /> ® l or 2 Family Dwelling-Number of Bed'.oms 3 / Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use ❑ City of <br /> ❑State Owned-Describe Use <br /> CSM Number CI Village of <br /> �' ?e, 3 j ©Town of Oa n%v <br /> III.Type-Of Permit: (Click only one box on line A. Complete line B if applicable) <br /> A.(Ai'New System/ GI Replacement System CI Treatment/Holding Tank Replacement Only riff Other Modification to Existing System(explain) <br /> B. b`Pemiit Renewal ❑ Permit Revision ❑ 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 /> M 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.DispersaUTreatment Area Information: <br /> Desir Flow(gpd) Design Soil/Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal-Area Proposed(sf) System Elevation <br /> Li so 6, , `f IV// 25- L'%/.7 5- <br /> /OLr6 /6;a /0'(.O <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units a ` o ;, <br /> V N New Tanks Existing Tanks U y n <br /> Y a <br /> at <br /> a. c.) vt r, C/) ✓ U a. <br /> Septic or Holding Tank <br /> /ODO /000 / /21ead.‹, Df <br /> Dosing Chamber <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POINTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber 'o ature MP/MPRS Number <br /> STEVEN R. CROSBY t - 227009 <br /> ' 608-849-8771 <br /> Jc— <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 7361 DARLIN DRIVE, DANE, WI 53529 r <br /> VIII.County/Department Use Only \ <br /> Permit Fee Date I ued Issui d Agent Signa <br /> pproved ❑ Disapproved $ Agent!fie- <br /> ❑ Owner Given Reason for Denial LiD 9 S / /) _./� A <br /> IX.Conditions of A pp rova/Reasons for Disapproval ..-- r . <br /> `( <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 inches in size <br /> SBD-6398(R. 1 HI 1) <br />