Laserfiche WebLink
,.‘4•4n4--b „ rte.. County <br /> 444_,, 5 ° ' Safety and Buildings Division Dane 13Y1"‘if/ B'' ' r1 201 W.Washington Ave..P.O.Box 7162 Solitary Permit Number(to be filled in by Co.) <br /> Sr. Madison,WI 537077162 <br /> ii,,--‘1,::',1 *. . ¢i r. /3-Jo/b- <br /> r�;a (�b sy / <br /> Sanitary Permit Application State TrmuaellenNumber <br /> In accordmtee with SPS 38321(2),Wes.Adm.Coda submission of this form to the appropriate governmental unit <br /> is required prior to obtaining o=hay permit.Note Appliatio f f POWIS are submitted to Project Address(if dilT rent than mailing address) <br /> the Department of Safety and Professional Service. Peacoat in Itp to for Dndary <br /> Purposes in accordance with the Privacy taws.15.04(1)(m).Slots. ere CTH Y <br /> I.Application Informal(on—Please Print All Information <br /> Properly Nick NOV j&Melissa Hartwig 4 2016 / mi l* <br /> 0907-18497604 / <br /> Property Mailing Address F,,yl ftt Ot is Health MOC Property Location <br /> 401 Sunrise Blvd. ntal HeA Govt.Lot <br /> laic <br /> city,stale Zip Code Phone Numb r Ith SE %t, SE t.section 18 <br /> Moscow,PA 18444 T 9 N; R 7(circle a one) <br /> II.Type of Building(check all that apply) Lot 0 <br /> ®Ior2 Family Dwelling-Numbs/ofBedrooms 4 1 Subdivision Name <br /> Block A <br /> ❑Public/Commercial-Describe Use <br /> ❑City of • <br /> ❑State Owned-Describe Use CSM Number ❑Village or <br /> 10666 <br /> ®Toren of Roxbury <br /> III.Type of Penult (Check only one box on line A.Complete line B If applicable) <br /> 't' Ei New System ❑Replacement System ❑Treatment/licking Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> List Previous <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWYS System/Component/Devi ex(Check all that apply) <br /> ®Non-Pressurized In-Ground ❑Pressurized Io.Gmund ❑At-Grade ❑Mound?24 is 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(Bpd) Design Soil Application Itate(gpdsl) Dispersal Area Required(st) Dispersal Area Proposed(s0 System Elevmion <br /> 600 / 0.6 / 1000 / 1000 Equiv. / 92.0',92.4' <br /> VI.Tank Info Capacity hi Total ((or Manufocnncr <br /> Goilom Gallons Units ,p E u <br /> New Tanks Existing Tanis <br /> '°La s3 $ S2 5 <br /> a`U y air GO a <br /> Sepiear notdag Trek 1200 /' 1200 1 Wieser x <br /> Dosing Chohber 800 • 800 1 Wieser x <br /> VII.Responsibility Statement-I,the tmderslgsed,assume responsibility for installation of the POSVIS shown on the attacked plans. <br /> Plumber's Name(Print) P`79's Siyr4 a MP/MPRS Number Business Phone Number <br /> ITT 6.I �" ,21/75 - 499'1-3 IA-043-6531 <br /> umber's Address(Street,City.Stale.Zip Code) <br /> Loa 4441,\1\ (A!& St , I'D) ay 4%( c soul eo-v) Nil 5 .v. <br /> VIII. unty/Dcpartment Use Only J <br /> Approved ❑Disapproved r.,,. Doric eat Issuing use L'� <br /> El Owner Given Reason for Denial s Lt' t I 17� e <br /> IX.Conditions of Approvot/Reasoas for Disapproval <br /> Attack is sompkte plans for the nslvm nod=limit to tae Cmnty only eat paper hot lest than a Iasi l laths to sine <br /> SBD-6398(It.I I/1 I) <br />