Laserfiche WebLink
county <br /> Safety and Buildings Division c(rA) <br /> dl ' �S <br /> Madison WI 533707707—7162 1400 E Washington Ave Sanita-r�ynPcrmil Number(to be filled in by Co.) <br /> �L�ps P.O. Box5l/ 13k,� <br /> ViYlOyn�?i �Tl/P�� <br /> Sanitary Permit Application Stutc'rransnction Number <br /> In accordance with SPS 383.21(2),Wi5.Adm.Code,submission of this form to the opproprsde govcrnmmdml min <br /> iS required priorto obtaining esonitary permit. Note'.Application forms l'orslate-owned l'OW"rS ine,clmincdro Project Address(ifunereal than mailing address) <br /> the Department of Safety and Professional Services. Personal infomlation you providemuy be used r,"i,eordary / <br /> u ous in accorded..with the Privoc Law,s. 15.04 1 st,Stats. /l b aja g/}rs[vJ L/L) <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name / Parcel# 07 0 3`/ ,2 37 18--,7 <br /> o e / "c-A ef` J S C50 S a/Saoo <br /> Property Owner's Mailing Address Property LoNnmdn,-t <br /> Z5 S aaA.l Lr G Govt 1-01 3— <br /> City.State <br /> Ciy.State ZiplCode phone Number y,, 'A, Section <br /> J-Aa'�(ird✓t �. Jo (JS/—/ s7 ,o(circleo <br /> T .37 N: Rasa <br /> It.Type of Building(checkall that apply) Lotti <br /> —C� <br /> 4or2 Family Dwdling-Number of Bedrooms Subdivision Name� y� <br /> Black 10 <br /> ❑Public/Cotnmercial-Describe Use - <br /> -- ❑City of _ <br /> ❑State Owned-Describe Use CSM Number 0Village of <br /> gown of fijA<e. L/i"Ke, <br /> 111.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. El Nme System 34.Itcpincemmni System ❑ 1}anuneriVflelding Tank Rcpbmenmaa Only ❑Oma,Mtdiecmlmor 1..,ong Syelem(.xplui, <br /> B. ❑ Permit Renewal ❑Pannillicvisian ❑Change of Plumber ❑I'crmil Transfer m New List Previous Permit Number and Dale lssucd <br /> Before Expiration Owner <br /> IV,Type of POWTSSystem/Co monent/Device: Checkalltltete IyL_ <br /> ❑Non-Pasunirod l o-Ground ❑ Pressurired In-Ground ❑ At-Grade ❑ Moond>24 in,ofsnitable said ❑Mound 124 in.nfsuitableseil <br /> Holding Tank ❑Omer Dispersal Component(explain) ❑liuniainuat Device(explain) <br /> V.Dit trial/Tr-ntmmll Are-Information: <br /> Design Flow(gpd) Design Soil Application Rme(gpdsl) Dispersal Arca Required(sf) Dispersal Arch Pinioed(s0 System Elevation <br /> V1.Tanklnfo Copneity in Total Hol' Manufacturer y <br /> Gallon Gallons Units <br /> Ncwl'vika L istluµTonka ° N � � � <br /> Swli.er urlding Tank -30(9o 3QOC• ' � '! �W_ <br /> posing Chamber <br /> VII.Responsibility St.tc.a.t- 1,the nndersh,N).Barnum respanribiliry far braiding.-of Inc POW 1'S shown an the almched plans. <br /> PlumbeisName(Ponl) Plumber's Signature hPrvilRSNam- Business Phone Number <br /> 227691 715-349-7286 <br /> WADE RUPSIIOLM <br /> Plumber's Address(Street,City,Marc,Zip Code) <br /> 1'OBOX 514,SIREN,WI 54872 1 i . <br /> VIII.Count /De artment Use Only <br /> Permit Pcc Date lssucd Issuing Agent Signature <br /> Approved ❑Disapproved s 3�S00 _4Y <br /> ❑Owner Given Russian far Denial <br /> IX.Conditions of ApprovaVReasons for Disapproval <br /> AuaeL m,un�plale ownsf"'he sy,won.ndsubmil1.the County Dolt to We,n.11ns thane 1. m c <br /> BURNETT COUNTY <br /> ZONING <br />