Laserfiche WebLink
• <br /> 1. County <br /> i ifi ; Safety gs 'l7 - H <br /> ® »t W.Washington and Buildin Ave.,P.O.Division Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> S <br /> Pv';' Pi Madison,WI 53707-7162 <br /> Sanitary Permit Application "State Transaction Number <br /> ber <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¢g ysecj.fpt,sdary <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. R E C E-j(V E <br /> L Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> JUN-3 1016 <br /> GOw-t. n41" 0512.- 16,7- 95fs0-0 , <br /> Property Owne s Mailing Address Property Location <br /> Public Health MDC <br /> (ZC>) C,- (2.k A Environmental Health Govt Lot <br /> City,State Zip Code Phone Number <br /> 5 C' %, SZ,.., '!,,Section <br /> 7r-12- 1_ �� ff � (circle one) <br /> l'4 �^-) _mil ? `� T N; R 12 _e one) <br /> II.T of Building(check all that apply) Lot# <br /> c9-4-or 2 Family Dwelling of Bedrooms Subdivision Name <br /> & <br /> Block C . <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> Q-T-own of pfb;te <br /> IIL Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' ❑New S yste m �R e lacement System ❑Treatment/Holding menrlHoldin g Tank Re p lacement Onl y 0 Modification cation 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 /> 0i:2-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 Soil Application Rate(gpdsf) Dispersal Area Required(st) Dispersal Area Proposed(sf) System Elevation <br /> G: a u `f Icy f sq.-2,s- �.3.4. <br /> VI.Tank Info Capacity in Total C of Manufacturer - `)T. - 41.3 <br /> Gallons Gallons Units B v o <br /> o c New Talcs Existing Tanks C, _ s 0 m <br /> aU m <br /> % ir.U a <br /> Septic o ttalamgTank ( b 11-- 1 'r-2 .,-' _.` l <br /> Dosing Chamber G -)3-0 1 ( _ x�.`b _"L <br /> VOL.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS It on the attached plaits. <br /> Plumber's Name(Print) /Plum Signature MP/MPRS Number Business Phone Number <br /> ,. L:C r- I-)-1,0 con t 7`7-lc.c..c.—/ 2 76 Y7`( _Ge S-75-/ G'SZ <br /> Plumber's Address(Street,City,State,Zip Code) -- <br /> -Z i C-,eoe, 1 c4r./-6.-a C.,_r--63s3y <br /> VIII.County/Department Use-Only <br /> pproved ❑Disapproved Permit Fee I Date Issued / Issui end ' e <br /> ❑Owner Given Reason for Denial $ y 31 6-6-Zot <br /> IX.Conditions of ApprovalReasons for Disapproval <br /> .9 LL CELLJ 7o-rAt rr(G- (S0, ra, Ffib • <br /> -* PRPPPRAb( ABAroon aho i °r< - ?"uric . <br /> Attach to complete plum for the system and submit to the County only on paper not Ins than 8 vs s II inches in rise <br /> ---> If g4D AN fzi XX CE ATV e(/e__ op/Y64, <br /> SBD-6398(R.11/11) <br />