Laserfiche WebLink
County <br /> Safety and Buildings Division <br /> p s _ 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> P S Madison,WI 53707-7162 <br /> E 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 1 m Slats. O <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name t Parcel# O 7 O/ aZ .3F/ 02 <br /> �Q /1'I/� .5 l5� 093 03gbo� <br /> ! Property Owner's Mailing Address Property Location-r.k I 12029 <br /> Govt.Lot <br /> City,State p Code �7 Phone Number y4 %,, Section <br /> J d / �9 (circle one <br /> II.Type of uilding(check all that apply) ..ee�� Lot# T�-�r`—N; R _E o� <br /> I or 2 Family Dwelling-Number of Bedrooms ✓ ;1?0 Subdivisto Name <br /> Block# / /f <br /> + ❑Public/Commercial-Describe Use <br /> ❑City of <br /> f <br /> i CSM Number ❑ Village of <br /> ❑State Owned-Describe Use 1 <br /> V'own of e3 i[J <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> 17 New System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> i 1 <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: Check all that apply) <br /> on-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/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units a <br /> 0 U U U y <br /> { New Tanks Existing Tanks S o p <br /> r� U inn y V) <br /> Septic or Holding Tank <br /> Dosing Chamber752 <br /> / <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 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 <br /> VI1I.County/Department Use Only <br /> Permit Fee Date Issued Issuing Agent Signatu <br /> Approved ❑ Disapproved $�"75 pD /o <br /> 41 <br /> Zozy <br /> [IOwner Given Reason for Denial Wt�^� <br /> IX.Conditions of Approvals easons for DisapprovalF+ ^1 <br /> ;e4 � <br /> iFolkw W CourHY <br /> atd Y�&k ref0;,,-erne/1�S ._ _- <br /> S�{s-;te m -Fo b�- IOCa�c� aree Kr I kS� r y �Z�o l '' G r T U 1 2024 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 inches in size <br /> t.s, !,,,Ai�;ounty <br /> Department <br /> SBL3-6398(R. 11/11) <br />