Laserfiche WebLink
;It',1R"i S(7:;: Cottnty <br /> 1 Safety and Buildings Division ,�j <br /> 1400 E Washington Ave Sanitary permit Number(to be filled in by Co.) <br /> I ''';K "'I P.O.Box N�2�-3�b G(4 (b $ <br /> "' Madison,WI 53707-7162 <br /> cs <br /> State Transaction Number <br /> Sanitary Permit Application <br /> in accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit <br /> I 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 Privacy Law,s.15.0 1)(m),Stats. <br /> 1 I. Application Information—Please Print All Information <br /> Pro erty Owner's Name Parcel# O 7 t9 d 6o'j ��� 7 a <br /> A) 1 t o © 5` <br /> Property Owner's Mailing Address ( p t Property Location ,n C- <br /> y Ono Is V'j Govt.Lot <br /> City,Sate Zip Code Phone NumberS67Y [IL,r I , <br /> _/` Section <br /> p` / (circle one) <br /> !7 !76 / T N. R <br /> H.Type of Bu lding(check all that apply) Lot# 11— <br /> IV <br /> l.w 2 Family Dwelling-Number of Bedrooms �2 Subdivision Name <br /> + Block# <br /> j ❑Public/Commercial—Describe Use �. <br /> ❑City of <br /> i ❑State Owned.-Describe Use <br /> CSM Number ❑Village of <br /> ;27� 77 XTownof 1 AzV;eA- <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> j §LNew System ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> i <br /> J <br /> I 1 List Previous Permit Number and Date Issued <br /> Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New <br /> } 3efore Expiration Owner <br /> 11IJ.Type of P WTS System/Component/Device: (Check all that a 1 <br /> XNon-Pressurized In-Ground ❑ Pressurized lu-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 /> 17.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> I 71.Tank lnfo Capacity in Total #of Manufacturer <br /> ! Gallons Gallons Units n ° U <br /> New Tanks Existing Tanks i y " y <br /> 0 <br /> a.U in . rn w c7 a, <br /> Septic or'Hahl7TFg+mI- 1670C) r �retj e-s �d <br /> Dosing Chamber <br /> i 'YII.Responsibility Statement-1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) re MP/MPRS Number Bsiness Phone Number <br /> 17JADE RUFSHOLM 227691 715-349-7286 <br /> plumber's Address(Street,City,State,Zip Code)1,�7 <br /> PO 3OX 514,SIREN,WI 54872 <br /> I <br /> M.Coun VI <br /> ty/De artment Use Only <br /> �Approved El Disapproved Permit Fee Date Issued I Ag Sign <br /> J $� <br /> El �� l0�51�� <br /> Owner Given Reason for Denial <br /> ff.Conditions of Approval/Reasons for Disapproval <br /> I <br /> OCT - 5 2021 <br /> Attach to complete plans for the system and submit to the County only on paper not Ams than <br /> S3A-6393(R0313) .. <br /> I �a , <br />