Laserfiche WebLink
' arv��o County <br /> I Al .::°\:.\ Safety and Buildings Division �a0e 111/ _ <br /> i! S / p") 201 W.Washington Ave., P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> a ,, Madison,WI 53707-7162 <br /> '�,� . A` <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 ,2,-C)0/(o- b°35- I <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 Xm),Stets. <br /> I. A. 'lication Information-Please Print All Information f: - ink /0,50 it / / <br /> Property Owner's Name V <br /> A.ton 4 S ..o Parcel Oi/O/ZS2/aZSS/e <br /> Property Owner's Mailing Address NOV 1 20 Property Location - <br /> .- 3 7 G r San k-Q Public Health MDC Govt.Lot <br /> City,State I Zip Code ETIMintia IMMO I Health Al Er '/., /144.-'h, Section J <br /> ( i-J . G(r-r C. 4J� I.7 _ b T (circle one) <br /> 'Ii Type of Building(check all that apply) "` Lot N N; R I E or W <br /> l or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block N <br /> ❑Public/Commercial-Describe Use ❑City of <br /> ❑State Owned-Describe Use CSM Number 0 Village of <br /> 6 Town of 6 u e'k<' <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. im,New System ❑Replacement System ❑Treatment/Holding Tank Replacement Only 0 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 <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 /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(sf) Dispersal Area P d(s t) System Elevation <br /> G00 / , `i' /� l ).--av /s/,-. q3 t g71%t a3,0 <br /> VI.Tank Info Capacity in Total Hof Manufacturer <br /> Gallons Gallons Units i; °_ <br /> New Tanks Existing Tanks 0 V L u ,. H. <br /> a.u .8 n . rnn iZ v a. <br /> Septic or Holding Tank r.A i G <br /> / <br /> Dosing Chamber •� L Meet 01-4- <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature 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, 9 <br /> VII County/Department Use Only <br /> Approved ❑ Disapproved Perm" Fee Date Issued Issuing Age . _ :, re <br /> 5 0� II Id . /,� <br /> ❑Owner Given Reason for Denial r -.4(Fiw /////////////jpjf <br /> ///V <br /> IX.Conditions of ApprovaVReasons for Disapproval <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8112111.inches in size <br /> SBD-6398(R. l t/1 l) <br />