Laserfiche WebLink
�t''`rR� County <br /> �r �'. Safety and Buildings Division Dir(„I <br /> fri•t 0 s fes`, 201 W.Washlr itt}fl Ave.,P.O.Box 7162 Sanitary Permit Number(to be filled to try Co) <br /> \ 's C� Madison,Wt 53707-7162 <br /> 4V.1 .4ff' f'.lr I Q 7n? L 3- Tort —voc)& <br /> Sanitary Permit Applica 'on 'SwcTrnruachanNumbcr <br /> In accordance with SPS 377].21(21,Wis.Adm.Cods,wbtnission of this form t the IMPropriate'gM'erntneaui/Snit <br /> is reviled prior to obtaining a sanitary permit. Note.Application lama for for st c-6waed POWTS are submitted to.. Project Address(if different than mailing address) <br /> the Department of Safety and Prafennronal Service. Personal information you provide may be turd for secondary <br /> purposes in accordance with the Privacy Law,a.15 04(1)(m),Stats. <br /> t. Application Information-Please Print All Information Same <br /> Pnuperty Owner's Name + Panel Y <br /> 5k,401Dalin + Z;n01.1 06M 0/1- 561v- 6 <br /> Property Owner's Mailing Address Property Location <br /> 15.6 1 5c)111 o 1 Aioi. Owl.DA <br /> City,&ate ZipCode Phone Number <br /> ii/t— '/ti I/ir Y., Seztiom <br /> )tfrc(1), WZ 53531 Gob- ,by 8yy9chalcmy) <br /> IL Type of Bulling(check all that apply) Lot 0 <br /> T 6 N; R /it e or w <br /> I it 2 Family Dwelling-Number of Bealroonts 3 Subdisrsron Name <br /> Block N <br /> ❑Pubiic,Vommcreu!-Dcacrthe Use Q City of <br /> ❑State Owned-Describe Use CSM NumberQ Village of <br /> XTownof PIA"fon 7 l <br /> 5/,r''2,5 <br /> Ell.Type of Permit: (Cheek only one box on Doe A. Complete line B if applicable) <br /> A" <br /> 0 New System 0 Replacement System 0 Treatment/Holding Tank Replacement Only ..jkOtber Modification to Existing System(explain) <br /> f3PLOHpp h o hi <br /> IL 0 Permit Renewal ❑Permit Revisits ❑Change of Plumber 0 Ptrtnit Transfer to New Its Previous Permit Number and Date Issued <br />' Before Expiration Owner <br /> , tem/Com 13-2011-03033 (6/24/2011) <br /> I V.Type of POWTS Spa poaea!lDeiice: (Check all that apply) <br /> Nino-Prexsareni to-Qrumd ❑Pressurized In-Ormaid 0 Al-Grade 0 Mound>24 in.of suitable roil 0 Monad<24 in.of amiable soil <br /> ❑Holding Tank 0 Other Disposal Compooeat(explain.) 0 Ptetreatrnem Device(explain) <br /> V.Dispersal/Treatment Arra Information: <br /> Design Flaw(gid) Design Soil Application Rate(gpdsf) Dispersal Area Required(sl) Dispersal Atka Proposed(sf) System Devon= <br /> VL Tank Toto Capacity in Total a of Menu fat turer <br /> Gallons Gallon Units it C 11 o b <br /> New iu <br /> Tanks Exmg Tanks . °2 ; a u <br /> d V ii c7 a <br /> SCPucaHatzaagTalk 1300 1300 1 Dalmaray <br /> VII.Responsibility Statement-I,the undersigned,auntie mponslbflty for Isatalladea of tha POWTS shown an the attached plans. <br /> Plumber's Name(Pim) Plumber's Signature ,� T*MPRS Number Bummers Phone Nuusber <br /> .i r •< T. 1�►..t fit+ `r / 2133?? 6 <br /> Phirrtber'a Address(Belief,City,Stats,Zip Code) '° >i�� <br /> ? -9Bfr-7rS 7 <br /> 9.o. Sok 5Gb• Gµ/h. X/l/, 53 55 / <br /> Viii.County/Department Use Only <br /> )�Approved 1 0 Dis - <br /> Permit Fa Date issuedltssung Agent Signature <br /> S04/27/2021 j I <br /> ❑Owner Given Reason for Dcaial 282.00 <br /> iX.Conditions of Approval/Rtauona for Disapproval <br /> Site plan (attached separately) shows reconnecting existing septic tank to <br /> to proposed 3BR home using 4" schedule 40 PVC. <br /> • <br /> Attach In naplrts plain fe the maven and submit to the County only an piper got lea thea I las 11 tither to etas <br /> SBD-6398(R. 11(11) <br /> i <br /> i <br />