Laserfiche WebLink
County <br /> . <br /> Safety and Buildings Division L�q N E <br /> IN <br /> 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in-by Co.) <br /> • Madison,WI 53707-7162 <br /> • <br /> 13-2021-00076 <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 arc 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 /> L Application Information-Please Print All Information WtY'C(1I) W 06E' 1 A I L <br /> Property Owner's Name Parcel# <br /> C)7tt— 1Ol" .;21&'1-O <br /> Property Owner's Mailing Address Property Location <br /> 24:3 FS-j C•?,C_t'' 14 P 1-), Govt.Lot <br /> City,State Zip Code Phone Number N,,t,, 1 Ni6 /, Section 10 <br /> (circle one) <br /> G LiS� t At 01 7A I T 7 N; R 1 i EorW <br /> TI.Type of Building(check all that apply) Lot• <br /> } Subdivision Dame <br /> El 1 or 2 Family Dwelling-Number of Bedrooms - ') <br /> Block h rpt 1 PY t-}t l..l....�j <br /> ❑Public/Commercial-Describe Use 0 City of <br /> CSM Number 0 Village of <br /> ❑State Owned-Describe Use7711-7 -"Er- F <br /> ©rTown of r <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ig New System { <br /> 0 Replacement System 0 Treatment/Holding Tank Replacement Only j 0 Other Modification to Existing System(explain) <br /> I <br /> List Previous Permit Number and Date Issued <br /> B. 0 Permit Renewal 0 Permit Revision 0 Change of Plumber 0 Permit Transfer to New <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> 0 Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑Holding Tank 0 Other Dispersal Component(explain)._ _ _ 0 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) System Elevation <br /> `j,,r) t_),i t G lam: 1.'--...1/I() 912, 911.7', 911.4' <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units E ° �°' <br /> `a c lel <br /> New Tanks Existing Tanks ' .c <br /> `'� c <br /> 11 n, jj in ,,, rn iz.0 P. <br /> Septic orHo14ng Tank 14-Fys) i(0 i MCIRI f~ <br /> r ..1.7 1 it/IC-7-iNf .. X <br /> Dosing Chamber '::::'1,-)(7) — _ <br /> VIL 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 ' -MPr/MPRS Number Business Phone Number <br /> Al;Or-CAA; '0 iv-le.,`y1 t›.(-• ,,_--/i--,..--(1_. t'.� 'Z'k-IL-5 >i;. 107 <br /> Plumber's Address(Street,City,State,Zip Code) / <br /> L';'-'13 6.-if i=iD_ k. L/\.i iNUr.i AKE E t L' ,I i X33`)"/ <br /> VIII.Connty/Department Use Only <br /> Permit Fee Date Issued Issuing Agent Signature <br /> kg Approved ❑Disapproved <br /> 0 Owner Given Reason for Denial 464.00 04/23/2021 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 Ins 11 inches in size <br /> SBD-6398(R. I1/11) <br />