Laserfiche WebLink
co.; i.,,,„I D Ih 6- tt ti \\11 g <br /> e`_ ,' !7 ty and Buildings Division County <br /> 20; W. ashington Ave.,P.O.Box 7162 • 0a..rL.e_. <br /> 'S ' V • t1adison,WI 53707-7162 Sanitary Pcrmit Numbcr(to be filled in by Co.) <br /> Depart ent of C•_ 't`t Bala. .DC I <br /> . s en1 I ieilth i 517990. _ <br /> anitary Permit Application SlatcTransac�tioyn,N/um�b(cr <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Codc,submission of this form to the appropriate governmcntal e i"t V `J ���� <br /> unit is required prior to obtaining a sanitary permit. Note: Application forms for statc-owncd POWTS arc Project Address(if dilTcrent than mailing address) <br /> submitted to the Department of Commerce. Pcrsonal information you provide may be used for sccondary <br /> purposes in accordance with the Privacy Law,s. 15.04(I)(m),Stats. U t g ^ J2 <br /> I. Application Information-Please Print All Information 1` J� <br /> Property Owner's Namc Parcel# <br /> v‘b hLn Sc„c..r t Z 05<-/- 06,0 7- o 5.2- 9.. go-0 <br /> Property Owncr's Mailing Address Property Location <br /> /`7 J J-� •.$ rC/Z Govt.Lot <br /> City,State Zip Codc Phone Number Li..) v.. Ai 44,i y., Section s' <br /> ,lite al'Se wi . .5 3.7 // ‘dg -.Y7�/- �Yo (circiconc) • <br /> H.Type of Building(check all that apply) Lot# T �o N; R 7 E or W <br /> tir I or 2 Family Dwelling-Number of Bcdrooms 3 Subdivision Name <br /> Block# <br /> • <br /> ❑Public/Commcrcial-Describe Usc • <br /> 0 City of <br /> CI State Owned-Describe Use CSM Number ❑Village of <br /> • 99 7G Town of �pr;na/4Gam.-/‹. <br /> III.Type of Pcrmit: (Check only one box on line A. Complete line B if applicable) <br /> A. 1°1 New System y ❑ Replacement System ❑TrcalmenUllolding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑ Permit Revision _ `— <br /> ❑Change of Plumber 0 Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Dcvice: (Check all that apply) <br /> ❑Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade XMound>24 in.ofsuitablc soil 0 Mound<24 in.of suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Ratc(gpdst) Dispersal Area Required(st) Dispersal Area Proposed(st) System Elevation <br /> 6 U U /. J 6, v J (o c)c� .=._,t s.2 lee- <br /> VI.Tank Info Capacity in Total 0 of Manufacturer <br /> Gallons Gallons Units ° o 0 v <br /> X/ U ..1 <br /> New Tanks Existing Tanks u H V .8 <br /> cr.v in .. v, wO a <br /> Septic Dr H,l4.g Tank ✓` �� /•Z u t tvJe: pZ` �' <br /> Dosing Chamber 6 So __ _ 45",;) / ✓ ,d, -x - <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 M 1MPRS Number Business Phone Number <br /> 41 W. Me; 1z ,4,-- „c_.- ( ), Sao i4 s--- 608- 93/-$id -3 <br /> Plumber's Address(Street,City,State,Zip Codc) <br /> CG'3 !3 U 1-1 "lc." J0,...,.«,r62-.c. W;_ 53s 7 <br /> Ap County/Department Use Only <br /> / <br /> rovcd ❑ Disapproved Permit Fcc� Date Issued Q Iss tng A nt S nature IQ,J • <br /> ❑ Owner Given Reason for Denial <br /> $ ��� �O`" 1 V -'i��J <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> — ___ KC P49,W,,7 AA6(4 'jnc-4(i <br /> Attach to complete plans for the system and submit lo the County only on paper not less than 81/1 x 11 Inches In site <br /> D6- 27170 cam- 3G 3°\S <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />