Laserfiche WebLink
County <br /> " '• Safety and Buildings Division X ell"rtJ <br /> u 1400 E Washington Ave Sanitary permit Number(to be filled in by Co.) <br /> P.O.Box7162 5A1\J-a.c-1J <br /> ' Madison,WI 53707-7162 <br /> G3/ys� <br /> 1 Sanitary pernit 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 are submitted to Project Address(if different than mailing address) <br /> the Department of Safety and Professional Services. Personal information you provide may be used for secondary <br /> purposes in accordance with the PrivacyLaw,s.15.04 1 m,Slats. <br /> 1. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# Q 7 C? ' ,3 J / 7/5- <br /> ,� a.J Y C15 vats <br /> Property Owner's Mailing Address Property Location�G/ <br /> O 6//C5 ©/,es �Sr Govt.Lot <br /> j City,State Zip Code Phone Number <br /> J/ p ��J /<,$G� /4, Section <br /> Gvl��'1 j�3 (circleon <br /> _ W <br /> 11.Type of Building(check all that apply) Lot# T �N; R f� E o <br /> 1 or 2 Family Dwelling—Number of Bedrooms <br /> Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use —^ <br /> �-'— ❑City of <br /> CSM Number ❑ Village of <br /> ❑State Owned-Describe Use Town of Z-V <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. New System <br /> y ❑ Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> t B l List Previous Permit Number and Date Issued <br /> ❑ Permit Renewal ❑Permit Revision El Change of Plumber ❑Permit Transfer to New <br /> Before Expiration Owner <br /> IV.Type of POWTS S steni/Com onent/Device: Check all that apply) <br /> Y,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/Treat ent Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Disper l Area Proposed(sf) System Elevation <br /> 3 D 0 y2 q ;oo <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons_ Gallons Units w o e <br /> New Tanks Existing Tanks w i <br /> a Un on w C7 a, <br /> Septic or m c /�j�v �� C� j �©1—ct/�s C_ Q <br /> Dosing Chamber l v <br /> VIE.Responsibility Statement- II,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Wer's Signature MP/MPRS Number Business Phone Number <br /> WADE RUFSHOLM / 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 <br /> V111.County/Department Use Only <br /> Permit Fee Date Issued Issuing Agent Signature <br /> Approved ❑Disapproved $ s.�. /I <br /> ❑ Owner Given Reason for Denial 3� 3 �'�L� 4) d( <br /> 1X.Conditions of Approval/Reasons for Disapproval ,_ .5 <br /> EC EOVE <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 Jln� in `��t� j ^0 <br /> 21 <br /> SBD-6398(R0313) L <br /> umett County 1 16.0 <br /> Land Services Department <br />