Laserfiche WebLink
.. rS 3.uev c� <br /> Safety and Buildings Division <br /> I D ; 1400 E Washington Ave Sanitary Permit Nun,ber(to be filled in by Co.) <br /> 4 y P s P.O. Box 7162 r <br /> Madison,WI 53707-7162 —�� J <br /> �'tgcrp�pY,- — <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 Services. Personal information you provide may be used for secondary ] / <br /> purposes in accordance with the Privacy Law,s.15.04 1 m,Slats. <br /> I. Application Information—Please Print All Information <br /> Property Owner's Name v Parcel# p 7 01 ;;Z / <br /> Z / e�r � S CSS OD { Q/3e>chC'N <br /> Property Owner's Mailing Address Property Location Pc'-/ <br /> Govt.Lot_ <br /> Ci ,State Zip Code ry PhoneNumber <br /> 2�{` 1A !3 <br /> ®, -0- D e/NT /L) ����'> I�5—1 /J d /S Section <br /> btrcle one <br /> I1.Type of Building(check all that apply) Lot# T N; R E o <br /> 3 4r 2 Family Dwelling—Number of Bedrooms <- Subdivision Name <br /> Block# <br /> ❑Public/Commercial—Describe Use r El City of <br /> ❑State Owned—Describe Use CSM Number El Village of r <br /> V/OP/ /A/ ; 'own of S1 ev/ s- <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A" ❑New System j %_Replacement System ❑ TreatmentfHolding Tank Replacement Only ❑ Other Modification to Existing System(explain) <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 /> N.Type of POWTS S stem/Com onent/Device: Check all that app 1 <br /> 9,40n-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.Dis ersal/Treatment Area Information: , <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(s f) Dispersal Area Proposed(sf) System Eleevon i <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units s o o <br /> tC U U TJ " 'A ' <br /> New Tanks Existing Tanks o g a ,�`d <br /> U vi y rn w Al a <br /> Septic or IloldingJank '��� •� <br /> Dosing Chamber <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 MPIMPRS Number Business Phone Number <br /> 227691 <br /> WADE RUFSHOLM �irJy C%r/G-- 227691 715-349-7286 <br /> Plumber's Address(Strcet,City,State,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 <br /> VIII.Coun /De artment Use Only <br /> Approved El Disapproved Permit^F7ee` D Date Issued Issuing Agent Sig <br /> M Lata�) <br /> 11 Owner Given Reason for Denial $ <br /> < " � ���l S <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> ll ! <br /> Attach to complete plans for the system and submit to the County only on paper not less than a M 111 inches in sine <br />