Laserfiche WebLink
County/1 <br /> ,..., - •,,, <br /> ,.. ,. Safety and Buildings Division )6/07'4 e....11— <br /> . -,.. <br /> z', 0 . , 201 W.Washington Ave., P.O. Box 7162 alc,I.v Permit Number(to be filled in by Co.) <br /> Madison,WI 53707-7162 <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 are 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(l)(m),Stats. <br /> I. Application Information-Please Print All Information ' <br /> Property Owner's Name Parcel# 6 7 0v 0 ,2 37/ei 3 5- <br /> GAry C h/etc p .e....)-1-e-i— _3 02 0 0 0 0/15-cA O <br /> Property Ovfner's Mailing Addrets Property Location <br /> /3 7© 7 S;stir.No k.-I Govt.Lot <br /> City.State Zip Code Phone Number ,4)14.) 1/4,_5 4) VI, Section 3-5 <br /> G" otiJ t-5 t qr9 cAIT .5.- xy 0 46 7--,71,30 -5:701 <br /> T :3 7 N; R /7(circle on <br /> E or0 <br /> IL Type of Building(cTeck all that apply) Lot# <br /> .,1 or 2 Family Dwelling-Number of Bedrooms ci? --- <br /> Subdivision Name <br /> Block# -- <br /> --- <br /> 0 Public/Commercial-Describe Use — ---, <br /> 0 City of <br /> ...----- <br /> - CSM Number 0 Village of <br /> 0 State Owned-Describe Use <br /> Town of Zdy Mills5.1,/4 odt,e j <br /> (---— <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. 1 — <br /> I Ll New System Replacement System 0 Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> i <br /> B. I n Permit Renewal 0 Permit Revision 0 Change of Plumber 0 Permit Transfer to New List Previous Permit Number and Date Issued <br /> I Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> )&1,\ion-Pressurized In-Ground 0 Pressurized In-Ground 0 At-Grade 0 Mound>24 in.of suitable soil 0 Mound<24 in.of suitable soil <br /> 0 Holding Tank 0 Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) I Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 7 V.2 Y.5—C) 75; <br /> VI.Tank Info 1 Capacity in Total #of Manufacturer <br /> Gallons Gallons Units <br /> New Tanks I Existing Tanks `.2, 6' (e) 172 1 <br /> .,7, 1.,-, &, <br /> Septic or riaiciiiTrrnk /2de) / 6/c-A Dosing Chamber <br /> Chamber <br /> i I 1 <br /> VII.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 MP/MPRS Number Business Phone Number <br /> WADE RUFSHOLM /l--r4)-4--- 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 <br /> VIII.County/Department Use Only <br /> 1 r-, Permit Feeoc, Date d Issuing A nt Sign <br /> Ni-- n Approved 1 Ll Disapproved <br /> I <br /> , LJ Owner Given Reason for Denial I 1 0%3 iiIsLl 1sue2? r C gWE n <br /> -.. <br /> EIS.--'= <br /> IX.Conditions cqApprolil/Realons for Disapproval <br /> 011 ee4- ct ii 5e4,4›..c.14 5 f 54-eck retiZiteW4L4S- IL(i it,Tt) W63 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 11 inctrarlIrS— -it melt County <br /> Land Services Department <br /> SBD-6398(R. 11111) <br />