Laserfiche WebLink
„ ANa+;', County l• <br /> 1 �,: Industry Services Division t�0.i�1�„� <br /> r. • e 1400 E Washington Ave <br /> 1� I` P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> Madison,WI 53707-7162 <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 <br /> the Department of Safely 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(I)(m).Stats. <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel tl <br /> 01/4.. sI. ,..)e,- >ii/t 41 teN 69 i Z. - i 2--z. V a e.c, :Property Owner's Mailing Address �� Property Location <br /> NI 1',” 1 ' f , J.p ,_ 2c0 Govt.Lot / ' <br /> Cit _,. t Zip Code Phone Number 1\IC'/.,Al PV'/., Section I Z.. <br /> (c IC one) <br /> Uwe a~ t. 1/ TCi}N : RitLo W <br /> II.Type of Building(check all that apply) L <br /> I or 2 Family Dwelling-Number of Bedrooms f ot Subdivision Na mc <br /> ❑Public/Commercial-Describe Use Block 4 <br /> • ❑ City of <br /> ❑State Owned--Describe Use ._.. ❑ Village of <br /> CSM Number Iv Town of YO if <br /> III.T pe of Permit: (Check only one box Orlin?. Complete line B if applicable) <br /> A. New System ❑ Replacement System' ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑ Permit Revision • ❑Change of ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) ' <br /> NI 'on-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> • siding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application, Dispersal Area Required(sf) Dispersal Area Proposed(sf) 4,t c Elevation .) of y g <br /> Rate(gpdsl)f 1 e 7 i 900 0 'q •,3 et c-(s• 3 <br /> 0 VI.Tank Info Capacity in ,u <br /> Total #of ° `-' <br /> Manufacturer ��+ u �, h <br /> New Tanks Existing Tanks <br /> Gallons Units a a U s 2 • ci. t�7 Q <br /> Septic oc.Roldittg lank 6 C'3 ' 6 9) ' /ct ♦/! il ' ❑ ❑ ❑ ❑ <br /> Dosing Chamber ._._... ❑ ❑ ❑ 0 ❑ <br /> VII.Responsibility Statement- I,the undersigned,assu j •ponsibility for installation of the POW shown on the attached plans. <br /> Plu is Name(Print) <br /> � <br /> V 'A <br /> berltgnayt✓ure„ PRS Number Business P ne Number <br /> woorlar r <br /> Plu ber's Address(Street,City, te,Zip <br /> Code) <br /> 0 f>(..) `7 (io C (0 tv..,6 ti S 1/1/1-- 5 5'2--.5--- <br /> VIII.County/Department Use Only <br /> pproved ❑ Disapproved m <br /> Permit Fee Date Issued lssui gem ig ure <br /> 0 Owner Given Reason for Denial S `i`a 5J8— t f 7 -I E D • <br /> IX.Conditions of Approval/Reasons for Disapproval Ol <br /> MAR 0 6 2017 <br /> Public Health MISC <br /> Frw1ronmQr)ttal Hon <br /> Attach to complete plans for the system and submit to the County only oapaperenot L e s s than 8 tO.x I I(tithes in um <br /> SB0-6398(803/14) AR, <br />