Laserfiche WebLink
rin*art.,4.r County <br /> Safety and Buildings Division <br /> ;_;; D4s'; 1400 E Washington Ave Sanitary PennitNumber(to be filled in by Co.) <br /> Y� P S P.O. Box 7162 <br /> Madison,WI 53707-7162 <br /> 4F� <br /> A-0 <br /> �$Il1ii PY <br /> Sanitary Permit Application StateT�rransactionNumber <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit 2/ <br /> 2 W16 <br /> is required prior to obtaining a sanitary permit. Note:Application forms for state-owned POWTS are submitted to Project Address(if different than[nailing address) <br /> the Department of Safety and Professional Services. Personal information you provide may be used for secondary <br /> purposes in accordance with the Priv w,s. 1 . 4 1 m,Stats. <br /> I. Application Information-Please' rini All Information <br /> Property Owner's Name Parcel# C114) 7 00 --rkl 7 <br /> A. GJ/S�/ O/'Yl cn//000 <br /> Property Owner's Mailing Address Property Location <br /> 16-:3(p,� .�J G�G�// ftJ t� /� �(� Govt.Lot <br /> City,Strar- ll Zip Code Phone Number �(� y, �, Section_7 <br /> _'V ! —2l 6 2/// cycle one) <br /> T 3t�N; RE <br /> II.Type of Building(check all that apply) Lot# or� <br /> or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> f Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> CSM Number ❑ Village of <br /> ❑State Owned Describe Use " <br /> Town of L/9.yt! <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑New System a lacement System ❑ Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. 11 Permit Renewal ❑Permit Revision ❑ Change of Plumber <br /> ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/C= o en vice: Check all that apply) <br /> ❑Non-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 Ratc(gpdsl) Dispersal Area Required(sf) Dispersal AreProposed roposed(sf) System Eleion <br /> vat <br /> y5 0 �5 e <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o $ <br /> New Tanks Existing Tanks o Z y <br /> WU in y rn WC7 0.. <br /> Septic or H&tdrFrffT5n1 00 a CIO <br /> Dosing Chamber _ OCJ 0�5G <br /> 47 <br /> VII.Responsibilitytatement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print)p, " Plumber's Signature MP/MPRS Number Business Phone Number <br /> WADE RUFSHOLM <j®L,/f227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 <br /> VIII.County/Department Use Only <br /> a� <br /> Approved 11 Disapproved <br /> Permit.3 <br /> O Date Issued Issuing Agent Sign atur <br /> ❑Owner Given Reason for Denial $3/-7`S' 7 r" <br /> IX.Conditions of Approval/R�`s+n§for Q,"pproval <br /> Q E C E 1.:! <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 112 x I l Ic <br /> h in Ulf <br /> --- <br /> ------ P3liRNE r T COUNTY <br /> ZONING <br />