Laserfiche WebLink
-•`,EiAtIvi County I <br /> „ A �f�° Safety and Buildings Division /�ry it. <br /> _ J <br /> IVs CANNED 201 W.Washington Ave., P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> ps Madison,WI 53707-7162 <br /> ,v <br /> `•'A\=� ' ( 3 . J01-7 - (...o001.1 <br /> \`,su,..a <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(I)(m),Stats. <br /> I. Application Information—Please Print All Information <br /> Property wner's Name Parc <br /> ,—,1 e,fir 1- S/,',-q;pi ,'4 !?c. N e u tr C5 /6.- ,to eaei v <br /> Property yOwner's <br /> �/Mailing Address q_ Property Location <br /> r d ; J �O/ 17 ri ,-r7 p f— Govt.Lot <br /> City,State J ! Zip Code Phone Number �41 1� .5 act _/, Section J O <br /> Mete t S nri / J 7', (circ ne) <br /> II.Type of Building(check all that apply) Lot ft T N. R /t! r W <br /> ❑ 1 or 2 Family Dwelling—Number of Bedrooms . / Subdivision Name <br /> Block if <br /> ❑Public/Commercial—Describe Use <br /> ❑City of <br /> ❑State Owned—Describe Use CSM i�ger2 ❑ Village of <br /> 4 Town of :11,..i el 12 <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. V -New System ❑ Replacement System ❑Treatment/Holding Tank Replacement Only rj Other Modification to Existing 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 /> 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 So�pplication Rate(gpdsf) Dispersal a Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> Ys� a , //Pc i/.� 9D, 3 '1'65- <br /> VL Tank Info Capacity in Total q of Manufacturer <br /> Gallons Gallons Units e)u u <br /> New Tanks Existing Tanks tag u = u u g 2 <br /> _---____ _ A-.c.) 7 h rn iia d <br /> Septic olding Tank /0 el /,art,u / 17/24/ ---� �S <br /> Dosing Chamber CC�� <br /> VII..Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number <br /> STEVEN R. CROSBY c--'/ �� - 227009 <br /> � <br /> 608-849-8771 <br /> � � <br /> Plumber's Address(Street,City,State,Zip Code) , <br /> 7361 DARLIN DRIVE, DANE, WI 53529 <br /> VIII.County/Department Use Only <br /> Approved ❑ Disapproved Permit Fee Date Issued [ssui gent Signature <br /> s <br /> ❑ Owner Given Reason for Denial 41(3 i _ <br /> IX.Conditions of Approval/Reasons for Disapp val _ '- ' I .) <br /> ' U,vA, APfrA (o 1 -k Rc <br /> FEB 0 6 2017 <br /> Public Health MDC <br /> Attach to complete plans for the system and submit to the CouJ 1 it grltr lsi IM1102 s I I inches in size <br /> SBD-6398(R. I I/I I) <br />