Laserfiche WebLink
i <br /> I <br /> County n l <br /> Jvanrarvr� !C <br /> �'-fi"' , Safety and Buildings Division �f��t l <br /> ' \f� 201 W.Washington Ave:, P.O.Box 7182 Sanitary Permit Number(to be tilled in by Co.) <br /> is "'' Madison,WI 53707-7162 <br /> ',t. s' 1 �l Oft <br /> 11) - a 1 -ono 3 <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 <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(l)(m),Stets. <br /> 1. Application Information—Please Print All Information S Q <br /> r,3 ,-lktrt✓ <br /> Property Owner's Name Parcel P <br /> GitA Lrnz /Pi ec't?i^ 0710 -, G - 1. '15- -O <br /> Property Owner's Mailing Address pp Property Location <br /> t i <br /> 3330 St��C.e.I kc�w d Govt,Lot, <br /> City,State ( Zip Code Phone Number 5 e /,4w %, Section 56 <br /> .�y� /� f 533-57i-' <br /> (circle one) <br /> !'/(,,clewI4n 1 Lat# T 7 N: R /0 EorW <br /> IL Type of Building(check all that apply) <br /> 13 I or 2 Family Dwelling—Number of Barrooms <br /> y Subdivision Name <br /> '< Block P <br /> " <br /> ❑Public/Commercial—Describe Use ❑City of <br /> CSM Number ❑Village of <br /> ❑State Owned—Describe Use A <br /> !y �1�3 El Towti of 81#1,)N„r 1 G e e <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' ®New System 0 Replacement System ❑Treatment/Holding Tank Replacement Only CI Other Modification to Existing System(explain) <br /> List Previous Permit Number and Date Issued <br /> 8. El Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New <br /> Before Expiration Owner <br /> IV,Type of POWTS System/Component/Device: (Check all that apply) <br /> Q Non-Pressurized In-Ground ❑Pressurized[n-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.Dis.ersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(st) Dispersal Area Proposed(st) System Elevation <br /> Gov , 41 lrOO I5ix 42g".b VL Tank Info Capacity in Total II of Manufacturer u � <br /> Gallons Gallons Units c 1 = <br /> New Tanks Existing Tanks a..ti iii . rn i,;V o. <br /> Septic oo-geidias Tank & —._ 1a Ft. ( er ie. i <br /> Dosing Chamber <br /> VU.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) " Plu ' Signature MP/MPRS Number A <br /> STEVEN R. CROSBY tft ' ' 227009 608-849-8771 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 7361 DARLIN DRIVE,DANE, VIII 53529 <br /> VIII.County/Department Use Only <br /> Permit Fee Date Issued Issuin g ant ur <br /> ISKArpproved 0 Disapproved $ 40 3-2.` t <br /> ❑ Owner Given Reason for Denial x <br /> IX.Conditions of ApprovalReasons for Disapproval <br /> RECEIVED <br /> • FFg zgy <br /> Attach to complete plans for the system aige a� ti i <br /> tor not less than s tiz x inches In size <br /> H Public Health MDC <br /> SRD-6398 IR. Il/Ili Environmental Health <br />