Laserfiche WebLink
tr;44^A►i County <br /> /,r�;t,w ''∎; Safety and Buildings Division Dane -�" <br /> ,a`4'`DS W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be Cilcd in by Co.) <br /> ice, P Bt; '. Madison,WI 53707-7162 <br /> ,.$` t 3- u (4 (x31` <br /> 1.1 <br /> Sanitary Permit Application state Transaction Number <br /> In accordance with SPS 383 21(2),Wis.Adm.Code,submission alibis form to the appropriate governmental unit <br /> is required prior to obtaining a sanitary permit. Note:Application tons(or state-owned POWfS are submitted to Project Address(if different titan 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.i s.O4(I)(m),Slats.^ E( I t�c r W. Blue Mounds Road <br /> L Application Information-Please Print All Informatio <br /> Propert ner's Name 1,a1 <br /> Andy&Kristin Davis OCT 0 6 2016 0606-204-8110-0 <br /> Property Owner's Mailing Address Property Locution <br /> 721 Blue Mounds Street Public Health MDC Gov of <br /> City,State Zip Code _. ' :" rlw:IT--- NE ib, SE Y+. Section 20 <br /> Mt. Horeb,WI .. 53572 one) <br /> II.Type of Building(check all that apply( J Lot{► T. 6 N; R 6 E or W <br /> 8 I or 2 Family Dwelling-Number of Bedrooms 3 / 4,/ 1 Subdivision Name <br /> Block it <br /> ❑Public/Commercial-Describe Use <br /> ❑City of • <br /> ❑Slate Owned-Describe Use CSM,,N bee ❑Village of <br /> 1 13951 Cgl Town of Blue Mounds <br /> III.Type of Permit: (Check only one box on line A. Complete line B If applicable) <br /> A./4 New System ❑Replacement System ❑Treatmentllioldin g Tank Only ❑Other Modification to Existing System(explain) <br /> H. ❑Permit 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 /> ❑Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ®Mound?24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑lloldingTank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: _ <br /> Design Flow(gpd) Design Soil Appeal' n Rate(gpdsl) Dispersal Area R had(at) DDispersal Area P (si) System Elevation <br /> 6'`450 C. _ P7r t ti'14 d 91.8' <br /> VI.Tank Info Capacity in T al it or r Manufacturer <br /> Gallons Gallons Units a u ` R <br /> New Tanks Existing Tanks 'Gs g t t .8.2 g <br /> 6U us w y L0 Tx. <br /> Septic or Holding Tank 1000 1000 1 Dalmaray x , <br /> Dosing Chamber 600 600 1 Dalmaray x - <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility fo tallatlen of the POl\TS shown on the attached plans. <br /> Pli mber's Name(Print) PI 's Signature i MT'(MPRS Nwnber Business Phone Number <br /> . c • L -dc ce. �' 2Zto85Z Cook-tli�S-�'3/y <br /> Plumber's Address(Street,City,State,Zip Code) <br /> Ct a ■ c*, Nk Ni-,5 k kz� 53s�Li <br /> - <br /> VI I.County/De artment �!►�,a,� <br /> Permit Fee Date of Issuing A ntSignature 'W W� <br /> N. t proved ❑Disapproved r t <br /> ❑Owner Given Reason for Denial S to /7 k_ ,c <br /> IX Conditions of Approval/Reasons for Disapproval <br /> �' <br /> Attach to complete plans for tho system anal submit to the County wily on paper not less than A la s I I Inches In size <br /> SBD-6398(R.l I/11) <br />