Laserfiche WebLink
��l �"� Safety and Buildings Division �f!'��� <br /> I3 ) 0 ; 1400 E Washington Ave Sani Permit Number to be filled in Co. <br /> P s P.O. Box 7162 YTS �j <br /> 'a �'��J Madison,WI 53707-7162 ����� 1 / <br /> �wwa/ S��I�f <br /> Sanitary Permit Application State Tranaacti°"Namher <br /> In accordance with SPS 38321(2),Wis.Adm.Code,submission of this fomt 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 Sewices. Personal infomtatiw you provide may be used for secondary <br /> u ses in accordance i[h the Privac Law,s.15.04 1 m,Stats. �/ �/ G <br /> I. A lication Information—Please Print All Information <br /> Property Owner's Name //�� Parcel# Q-� Q�ZQ <br /> C �.n�� e nJ K,� ,��5- oo� a l9fa©a <br /> Property Owner's Mailing Address �, Property Location <br /> / 6.;Z� a res U��c.,J G n1 <br /> Gov[.Lot <br /> City,State fj/) Zip Code Phone Num�b}er +/,, %., Section � / <br /> /� / / ! '' I� ! I iil `�5,3�� � O �� �Zf S� (circle one <br /> T�_N; R�Eo�V <br /> II. pe of Building(check all that apply) � Lot# <br /> �or 2 Family Dwelling—Number of Bedrooms Subdivision Name <br /> Block# <br /> ❑Public/Commercial—Describe Use ,�— <br /> ❑City of <br /> ❑State Owned—Describe Use CSM Number ❑ Village of � <br /> 1�� ��� �-Town of ©l'ix K <br /> IIL Type of Permit: (Check only one boz on line A. Complete line B if applicable) <br /> `t' ❑New System l�teplacemen[System ❑ Trea[ment/Ilolding Tank Replacement Only ❑Other Modification[o Existing System(explain) <br /> B• ❑ Permit Renewal ❑ Permit Revision ❑Change of Plumber ❑Permit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> Before Expiratio�t 'I ! Owner <br /> IV.T e of POWTSI S stemlCom onenUDevice: Check all that a 1 <br /> Non-Pressuriud 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.Dis ersal/Treatment Area Information: <br /> Des'gn Floes gpd) Design Soil Application Rate(gpdst) Dispersal��aired(sf) Dis�al��posed(sf) Sym Elevation <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> H' 'GallorlSl Gallons Units � o 'd v <br /> New Tanks Existing Tanks � ppc � � � A � <br /> /q,, w U rn � w C7 6. <br /> Septic or 1 ��+ � 7�� L'� � C®,/G �JG <br /> Dosing Chamber <br /> VII.Responsibility Statement- I,the undersigned,assume respousibility for iustallatiom of the POWTS shown oa the attached plums. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> WADE RUFSHOLM � / �L`— 227691 715-349-7286 <br /> Plumber's Address(Streak City,State,Zip Code) /G� <br /> PO BOX 514,SIREN,WI 54872 <br /> VIII.Coun /De artment Use Onl <br /> Approved ❑ Disapproved Pem?tit Fese O Date issued issuin�n�gnature <br /> ❑ O ner Given Reason for Denial $J �"� � 7—��J�S <br /> IX.Conditions of ApprovaUReasons for Disapproval <br /> CG���'�„� Attach to complete plans for the system and submit to the Couaty only on paper not leas than a ta:[t inches in siu <br />