Laserfiche WebLink
County L-1- <br /> /t—�\°; Safety and Buildings Division U U rA)e-'l I <br /> S,: Ij 201 W.Washington Ave., P.O.Box 7162 Sanitary Permit Number(to he filled in by Co.) <br /> Is III Madison,WI 53707-7162 <br /> �% 5ss5�7 RJ <br /> Sanitary Permit Application State Transarion Number <br /> In accordance with SPS 38321(2),Wis.Adm.Care.submission ofthis form to the appropriate governmental unit 111eJ <br /> is required prior to obtaining a urinary,permit Nola:Application ibmv for state-owned POWTS we suhm hard to I'mjcot Addwsx l i fill precut Nan mailing add.,,,) <br /> the Department of Safety and Professional Servics. Personal information you Provide may be used for seoondary <br /> purposesin acce rdaaca with the Pnxacv law,s. ISM 1 m.Stats. <br /> I. Application Information-Please Print All Information <br /> Property Owacr's Name Parcel p 0 7 0 3 6 <br /> G e,,ihorn of o03 0/1000 <br /> Property Owner's Mailing Address Progeny Location E& aG blaf4 .?o Acer <br /> t—y-A 57'- Govrlat '3 <br /> City,State -/ Zip Code Phone Number /" <br /> ri y &, Sectionl2 <br /> Z /oT R A/ J y5z7 &// 6 -5-96-6 ,/ (ouele one) <br /> II.Type of Building(check all that apply) Loop T ryO N; kEor® <br /> �1101 2 Family Dwelling-Number of6adrooms 2 Subdivision Name <br /> Block a — <br /> 0 Puhlielcommercial-Describe Use �l <br /> Cory of <br /> ❑Slate Owned-Dseribe Use —� CSM Number El village of <br /> -0-row.of 1;:� AN r. <br /> III.Type of Permit: (Check only one box on line A. Complete line B ifapplicable) Ll <br /> A. Aft] ❑ Re placement System U'frewment/Holding'I ark Replacement Only El Office Modification It Existing System(explain) <br /> B. 0 Permit Rental 0 Permit Revision O Changeuf Plumber 01'crt9'mnsfcr m New List Pmviovo Permit Nber and Dme Issued <br /> um <br /> Before Expiration ' . <br /> IV.Type of POWTS 5 stem/Com anent/Device: Check all that a I <br /> j1tdomPressuriud In- round 0 PrtsswireA in- wund 0 At.Gmdc U M.und>24 ur mf unable soil 0 Mound<24 in,a]suitable soil <br /> UHolding Task U Other Dispersal Component(explain) U Pretremmem Device(explain) <br /> V.Dis ersal/Trcatman[Area Information: <br /> Design Plow(gpd) Dcsign Soil Application Rate(gp bl) Dispersal Area Required On, dispersal Area Proposed(sq S)atcm Elevation <br /> ,3oo `/,2 9 q5-6 95; <br /> VI.Tank Info Capacity in Total itor .Manufacturer <br /> Gallons Gallons Units <br /> New farts Eusu.g Tads <br /> Sir . 0 C <br /> D-u-9cluabrr <br /> VII.Responsibility Statement- 1,the undrrsignrd,assume.....mobility for installation of the POW'TS slum.on the attached plans. <br /> Plumleis Name(Print) PIFs Signore MPIMPRS Number Business Phone Number <br /> WADE RUES]IOLM / 227691 715-349-7286 <br /> Plumber's Add.,(Street,City,State,Zip Calc) oeloi <br /> PO BOX 514,SIREN,WI 54872 <br /> VIII.Count /De urtmentlAc OnI <br /> Approve) ❑DisapP,ovcJ Permit tic DNale//kowd issuing Age nature <br /> U Owne,Give.person for Denial sI�25-Z LY _ 1,)I <br /> IX.Conditions of Approv lb Reasons for Disapproval <br /> Aurc m,a a m r 11 soon',,ie,he <br />