|
,toyAK,ok-v, County
<br /> -`-! °,, Safety and Buildings Division P cli +1(.,
<br /> x(xD , ,;::.;; 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be tilled in by Co.)
<br /> ,', 4 s1,' ) A y 7 Madison,WI 53707-7162
<br /> \ 3 :._�i./ / -20))_ tact) LF+
<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 govemmental 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. 571/6 S(�
<br /> I. Application Information-Please Print All Information .QLT�S
<br /> Property Owners Name Parcel#
<br /> /vin 1) M4rie/Ye. 14Ii 1'6 441 ,� etA41 1..2. 4., 0 e7d' - ) 10 - 'Svt= --
<br /> Property Owner's Mailing Address Property Location
<br /> J ,f j7�i HA/1�.y Rd., Govt.Lot
<br /> City,State ' ' ( Zip Code Phone Number . ti/i411/4, 4/te/A, Section 1 a
<br /> +-^✓ Cl tS 7't,/G) t.e_e_ .1 i �J 3 & ,f.circle one)
<br /> (� f T N; R a E or W
<br /> H.Type of Building(check all that apply) Lot#
<br /> 0 l or 2 Family Dwelling-Number of Bedrooms Subdivision Name
<br /> Block#
<br /> ❑Public/Commercial-Describe Use
<br /> ❑ City of
<br /> ❑State Owned-Describe Use CSM Number 0 Village of (-
<br /> -Town of .61>r, bi• 2`-)-r_ Z 4
<br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable)
<br /> A' ❑New System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only Other Modification to Existin g 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 /> )II-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 Proposed(sf) System Elevation
<br /> CC --- __
<br /> VI.Tank Info Capacity in Total #of Manufacturer 2
<br /> Gallons Gallons Units o o ° .0
<br /> New Tanks Existing Tanks ' c 8 2
<br /> o. 0 in . v wv n.
<br /> Septic or Holding Tank t 3,,, 1 1)L, / /i2 t+ yZCLZ-_
<br /> Dosing Chamber �='
<br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for install on of the POWTS shown on the attached plans.
<br /> Plumber's Name(Print) Plumber Sign tune _ MP/MPRS Number 1
<br /> STEVEN R. CROSBY '� 227009 608-849-8771
<br /> .e- r_____,
<br /> Plumber's Address(Street,City,State,Zip Code)
<br /> 7361 DARLIN DRIVE, DANE, WI 53529
<br /> VII ounty/Department Use Only
<br /> Approved ❑ Disapproved Permit Fee Date Issued Issuin atur
<br /> ❑ Owner Given Reason for Denial $ i -3//2/i 7 / � / �/,
<br /> IX.Conditions of Approval/Reasons for Disapproval ll ® E �.f "
<br /> k 7,4-0,44///l/S,�7-4 /0/,‘,S _ 'v FEB PP-ogG,e/i/i 2 8 2017
<br /> ilk?-60• Public Health MDC
<br /> Ftwi}o. riaentaI Health
<br /> Attach to complete plans For the syst �.,. pis L,%,s on paper not less than 8 1/2 x t l inches rn size
<br />
|