HomeMy WebLinkAbout020-162-00-0300-SAN-2023-023 --- --
, '" Industry Services Division County �
% ' 4822 Madison Yards Way �a �-'�y�� �
��sr� �R= = Madison,WI 53705 Sanitary Permit Number(to be filled'm by Co.;
� �= P.O.Box 7162
��'�+,.'�_ ;�`i Madison,WI 53707 7162 (� '��( 3t-( S �
Sanitary Permit Applicatio ���5 S -� State Transaction Number �
c�a�oa� — �
In accordance with SPS 383.21(2),Wis_Adm Code,submission ofthis form ro the a ropnate governmental un-
is required prior to obtaining a sanitary permit Note:Applica�n foims for state-owned PpWTS are submitted to Prnject Address(if different than mailing addre JJ
the Depariment of Safety and Professiona!Services.Personal information you provide may be used for secondary
purposes in accordance with the Privacy Law,s. 15.04(I xm),Stats. /�
I.App6ca6on IHfore�ation—Pkase Print AII Information y7 yG �l� OJ�b 4
Properiy O�y�er's ND'l0( � J . Parcel#
r:�t n l � �� �. D,ZC�- ���. - �� � fl 3 O D
Property Owner's Mailing Address propeny Locatioo
�5,3 1 f �l $� .
City,State Zip Code P6one Number
�' F!(.1,✓4 dq ��S �it/f �y �i2 7/S �y� �pQ L /l�GtJ/,, y� �/a, Section Z
II.Type of Baildieg(c6eck all t�at appty) 3 Lot# � T 3� N R � E o�
�1 or 2 Family Dwetlmg-Number ofBedrooms Subdivision Name
Block# � {�r,Q,`S"�
D Public/Commercial-Describe Use
❑Ciry of _
�� �State Owned-Descn�be Use CSM Number ❑Vitlage of
�
�i'own of /'�,��bG✓�i
III.Type of POW'CS Permit=(Check either"New"or"Replacement"a�d ot6er applicabte on li�A. C6eck one box on lene B.Complete tine C i
a licable.
A' �iew S s�em ❑ R acement S stem ( p )
y epl y ❑ Other Modification to F�cistmg System{eacplain) ❑ Additional Pretreatrnent Unit ex lain
B' �Hotd'm Tank ❑ In-Ground ❑At-Grade
g ❑ Mound ❑ Individual Site Design ❑ Other Type(eaplain)
(conventional)
Reaew�ai Befare evision ❑Change of Ptumber ❑Transfer to New Owner �t Previous Permit Number and Date Issued
F�cpiration pZ t — �O� ; y a 6 /d �
. i nt Area and Tank Information:
Design Flow(gpd) Design So�l Application Rate(gpd/s� Dispersal Area Requved(s� Dispersal Area Proposed(s� System Ekvation
3 v o -�- — � ---
Capacity m ToW #of Manufacturer
Tank Information Gallons Gallons Units � � o � o
New Tanks Existmg Tanks � � � � � A � �
0
a.U v� m �n C�. C7 0.
Septic or Holding Tank r?�� V �,.� �K I �✓��vJL/� „�-./�/L° X
J
Dosing Chamber
V.Responsibility Statemeot- 1,tie aodersigued,ass��c respoasiblity far issta�atiea of t`e POWTS showo oa t6c attaehed phes.
Plumber's Name(Print) Plumber's Signature PRS Number Busincss Phone Number
m 1� n'1 b►�'}� '
`�'!� �?.2 S�G 9 '7 iS:1 GG - �af�h
Plumber's Address(Street,City,State,Zip Code)
Y✓7D� V*'� �iLa-T��^' /`d + �'i`" W��vt�! r �il)� � � v /V
VI. 0 1Department Use Onty
� r ❑Disapproved 1'ermit Fee Date Issued Issuing Agent Signature '
❑Owner Given Reason for Denial � l��.� 7 I � � I�3 ' "I Lc��'`� ✓��`i-
Conditions of Approval/Reasons for Disapproval '�� r '? ,�"�, � '� �r�
" �
, � � � � 3 � - �A� ��� � ��
}
�� ' ��► ��a�� 3 tr_ � � ��.�.
L �_-.-�
�
r--- ;:hk# t oro i -----___ _
.
C5� N��-- (�. N� �,�� l� �-�� z�;:..._ _ -:� _ :
Attach te comQlete plaas tor the system and s�bmit to lke Conaty oaly on paper sot le4s thao 8 trz z i(inc6s ia siae
NO REFJt�DS AF7ER `�� �'�`�
�SSUC OF PERNI�