Laserfiche WebLink
Cou/n1ty <br /> Safety and Buildings Division �l U rA) (�, <br /> I' $ 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> PS' P.O. Box 7162 �7 <br /> A S <br /> I i Madison,WI 53707-7162 7 /_3� <br /> Sanitary Permit Application Sratc'I'renmdion Numbcr <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this farm to me.,,.prime go,00r awl unit <br /> i5 required prior to obtaining a statuary permit. Note:Application forms for state-owned POWYS are submitted to I'mjeet Address(ifdilfcrcm man mailing address) <br /> the Department of Safety and Professional Services. Person.l infomtmion you provide may be used For secondary -'1 t/ <br /> purposes in accordance with the Pinna Iaw,s. 15.04 Igoo),Stats. O� / 6'0 <br /> l/ I <br /> 1. Application Information-Please Print All Information ��ie/ ryjt/ LJJ <br /> Property Owner s Name <br /> T L Parcel. p 7 "'y o7 3S'/5' <br /> V /Do I C/e/n¢.N/ O.�5 D3 OOI o3000n <br /> Property <br /> ppOwner'sMailing Address Property LacaliunP�j <br /> city.$last Zip Codc More Number Govt.Lot_ <br /> 11 53503.7 — —Z•_'d, Section 1_ <br /> 114 iJ I nJNndone� <br /> c <br /> II.Typeo uilding(eh,ck all that apply) Loth TqLLQ' N; RL EofWj <br /> fi3i.or 2 Family Dwelling-Number of Bedrooms 2 _ Subdivision Name -- <br /> Mae 4 <br /> ❑Publir/Commemial-Desuibe Use _ <br /> 11 City of <br /> �- <br /> ❑Stine OwneJ-Describe Use CSMNumb,r Q Villa I ge of <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑ New System X' Repinccment System ❑l'rcatmcnVH.Milit Tank ltc,imecmma Only ❑Omer Modifie.tlon to posting System(explain <br /> B• ❑ Permit Renewal ❑ Permit Revision ❑Changeofl'limber ❑rcmiarranic'm Ncw List Previous Permit Number mtd Date Issued <br /> Before Expiration Owner <br /> IV.Type ofPOW lo,S stem/Com onent/Devels: lCheck all that apply) <br /> ❑Non-Pmemehaed In-Ground ❑Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in,ofmotable soil ❑ Mound<24 in.of suitable sail <br /> ,XHolding Tank O Other Dispersal Com,nnent(loadaild 111'retrestment Dovice(explain) <br /> V.Dis ersabTrentment Area Information: <br /> Desi n Flow(gpd) Design SoilApplication Itah(gpJsl) Dispersal Arca Rcyui.J(s0 Dispersal Arcn Proposed(sQ System Elevation <br /> Vl.Tank Info Capacity in Total 9 of Manufacturer <br /> Gallons Gallons Units a u <br /> New Tanks Existing Tank, 'O <br /> dU y � <br /> Seryicnrlheding Tmtk a.S00 . S� e�rn <br /> oovna C3amba <br /> V11.Responsibility Statement- 1,the underslgnN,nsuna responsibility for Installation or the POMTS shown on the attached plans. <br /> Plumbers Name(Print) Plumber's Sign.mm MP/MPRS Numbcr B-mess Phone Number <br /> WADE RUFSHOIM /.i /_ 221691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 <br /> Vlll.Count /De artment Use Billy <br /> Approved ❑ DisopProved penot F. Dat,Issued Issuing Agent Signaurc <br /> 7a-�y G-.,5 �►enwc.� <br /> ❑Owner Given Reason for Denial s 375=Oe <br /> IX.Conditions of ApprovaltReasons for Disapproval <br /> l /F /fu7GDj.vG Sez�EK'- ovgX iI Fri, <br /> ' �f/a/X 70 BE t 'T- aF <br /> FGoaT,Ptf/lat! �CI` SEP — 8 2014 v <br /> Allach to complete plana for the assets.ad submit to the County only on papermt los man at as 1 13 <br /> Uin tie, <br /> RNETT COUNTY <br /> " " ' ZONING <br />