Laserfiche WebLink
t <br /> �_ Industry Services Division Q t T <br /> Is `. S ! 1400 E Washington Ave ( t <br /> 1. , . <br /> Q Sanitary Permit Number(to be filled in by Co.) <br /> A S P.O. Box 7162 <br /> -;,4. �.%r/ Madison,WI 53707-7162 <br /> < sti� ,,� t ?/./1 _:,r r?rth lDRVI i i 3— J°l 6.._ 00 38-7 <br /> Sanitary Permit Application 3A& 2:041 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 <br /> the Department of Safety and Professional Services. Personal information you provide may be used for secondary Project Address(if different than mailing address) <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m).Stets. <br /> I. Application Information-Please Print All Information I <br /> Property Owner's Name <br /> Parcel <br /> (WI(f i- i/n /Vet c e Mi.). I I 90,o ? <br /> Property Owner's Mailing Address <br /> Property Location <br /> fir? ) e_rrel i CS pd <br /> Govt.Lot <br /> City,State a Phone Number � F V..N E +/:, Section I <br /> g t_,r�°'t,1! 14.).I 3.3.�.. I I.2 P 519 P-1-18•190 /T� N (c a one) <br /> !j ; R l ei% (5.6r lV <br /> II.Type of Building(check all that a ply) a' Lot R <br /> X1 or 2 Family Dwelling-Number of B rooms r^ Subdivision Name <br /> ❑Public/Commercial-Describe Use Block f <br /> ❑State Owned-Describe Use ❑ City of <br /> CSIvlNumber? _ ❑ Village of <br /> 1/ 3 cI) ix TOWnof Aikn>r <br /> iII.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. fgNew System ❑Replacement System ❑Treatmeni/Holding Tank Replacement Only <br /> P I ❑ Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑Change of i ❑Permit Transfer to New ` List Previous Permit Number and Date Issued <br /> Before Expiration Plumber - i Owner <br /> I V. Type of POWTS = ((( <br /> yp O TS S}stem/Component/Device: (Check all that apply) <br /> IZI Non-Pressurized in-Ground ❑Pressurized in-Ground ❑ At-Grade ❑Mound>21 in.of suitable soil ❑ Mound<21 in.of suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> I <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application I Dispersal Area Required(st) Dispersal Area Proposed(sf) I System Elevation <br /> (_ O tl Rate(gpdst) ....% / <br /> (1� .. J j / Zt; / 202) I /i)7 510 1/44.5-- <br /> VI.Tank Info Capacity in I I <br /> Gallons <br /> Total f e of <br /> 3 <br /> j Manufacturer a 2 J r ri <br /> NetvTanls Existing Tanks i Gallons 1 Units ` 3 .9 c 7 I j <br /> Septic ot:iiolding Tank I I NI ?' rf,� l�r, 7 'i/1 ❑ ❑ ❑ I ❑ <br /> Dosing Chamber I !V I I I P.olinara i c1?-� V ❑ n in IQ <br /> VII.Responsibility Statement- I.the undersigned,assume responsibi ty for tstallati I n of the POWTS shown on th5 attached plans. t-•t <br /> PlumbNnKeeNEPILS EXCAVATINCP&t"ber I 1 gn re MP/MPRS Number Business Phone Number <br /> Plumber's AnanneetraillitylifekeleF <br /> Janesville,WI 53545 <br /> VIII.County/Department Use Only <br /> Approved ❑Disapproved Perrm/it Fe, yQ I Date Issued Issuing 1. at <br /> ❑Owner Given Reason for Denial S T3f '+ I(2 15-44r 31 C 2.4414--- <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> i €(124liZes N6/1/4111/kC YA-/Pa.02 A/1 , ' .- FIVED <br /> � <br /> � C i 3 2o16 <br /> Attach to complete plans for the system and submit to the County only on gaper not less than a In x i i inches in siz• - <br /> i',,''',i-rlealth MDC <br /> 5BD-6398(R03/1=1) or:mental Health <br />