Laserfiche WebLink
,/,�* *;,� Industry Services Division County n C <br /> �\,., 1400 E Washington Ave (,fin <br /> ,` 1 0 ,i \ P.O.Box 7162 <br /> a1;s_ Sanitary Permit Number(to be filled in by Co.) <br /> \ 4 $ ,.-/ Madison.WI 53707-7162 <br /> is- a v po/b <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 fonns for state-owned POWTS are submitted to Project Address(if different than mailing address) <br /> the Department of Safety and Professional Services.Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. <br /> I. Application Information–Please Print All Information <br /> Property Owner's t Parcel# <br /> /I/il/i4r1 F L e l#s o81a—/q)- 8676 — c. <br /> Property Owner's Mailing Address RAJ Property Location <br /> 55 a o k, e ROcl& Govt Lot <br /> City,State l ` f/ Zip Codde,� �j Phone Number r3 7 �/, 'v4 Section <br /> l etr3A4l/. "t/ ! 3.�Z,.1 / coo—ci g— 705/ (circle one) <br /> II�vpe of Building(check all that apply) T 1\, R E o�v <br /> �__ Lot <br /> or 2 Family Dwelling–Number of Bedrooms j Subdivision Iv*azue <br /> ----. Block# <br /> E blic/Commercial–Describe Use <br /> 1111ity of <br /> 2 ate Owned–Describe Use CSM Number (�Hinge of <br /> [ own of /urea i nu <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A" °0 ew System I Nrieplacement System El reatment/Holding Tank Replacement Only t 4erModificati to sting System( plain) <br /> U:SConncr `/,E KCVO/1/We r <br /> o� �g n� n° List Previous Permit Number and Date Issued <br /> B. rmit Renewal it Revision �hange of Plumber t Transfer to New <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Com•onent/Device: Check all that al .1• <br /> Non-Pressurized In-Ground iv ressutized In-Ground ID t-Grade El ound>24 in.of suitable soil—Mound<24 in.of suitable soil <br /> E:olding Tank Et Cher Dispersal Component(explain) Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf)1 System Elevation <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units <br /> New Tanks Existing Tanks a ) 1 i <br /> 0 ink wry <br /> Septic or Holding Tank /-Deo j� �J.y '� <br /> Doswg Chamber /6'3 7 Z f <br /> VII.Responsibility Statement- I,the undersigned,assume re ponsibility •r tns allatlon of the POWT own on the attached plans. <br /> tier's Name(Print) Plumber' S go tire /MFRS Nrnnbe Business Phone Number <br /> l 1 1 ( )_ 6635\0 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> a6 ON -C ) \\A-LL , 55- 9_ f--7_ , ---------„,:: <br /> VIII. nty/Department Use Only j <br /> El) ppro'ed 09 sapprrnved Permit Fee Date Issued / suing s- 4!�.tore 1�$ rner Given Roason for Denial S� 1 /7;Arrl'A''' <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> X. <br /> '2ci$r/Avg , i/e /! Ta .J.- fuM/ti d` /#s/' rev 'PAPA <br /> 7d F/ti9-a ♦wsPe4Pro v /44i' r lifr Z 5"- // /z ovror`&-----...__.�_._._�__.R.=' CETV Li <br /> see4ifroov e-A r.I'.v,A re. • 84,..oiwa./Ptt/,... <br /> APR 2 4 2017 <br /> Attach to complete plans for the system and submit to the my on papa not less than 8 L2 z 11 inches hi sloe <br /> j4N E Public Health MDC <br /> Environmental Health <br /> SBD-6398(R 08/14) <br />