Laserfiche WebLink
��a��4ARt4Y O CO <br /> tSafety and Buildings Division <br /> i 1400 E Washington Ave Sanitary Permit Number(to a filled in by Co.) <br /> S P P.O. Box 7162 <br /> S C� <br /> ,a a/! Madison,WI 53707-7162 — <br /> c�xtan+ <br /> Sanitary Permit Application State Transaction Nu er <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit ca�wfy PdPt W <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 ot'SafeJ and Professional S4iecs. Personal information'you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s. 15.04] m),Stats. <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name 11 Parcet# O 7 O 3 <br /> Property Owner's Mauling Address4 Property Location c- <br /> ff//0-?/ /11i X/T�S �� /�O/ Govt.Lot <br /> City,State "Zip Code Phone Number y, 1 / <br /> f /., Section <br /> circle one) <br /> T�_N; REoI�E) <br /> H.Type of Building(check all that apply) Lot# <br /> or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block# <br /> ❑Public/Commercial-DescribeUse El city of <br /> _�- <br /> CSM Number <br /> El <br /> Owned-Describe Use El Village of <br /> _ <br /> Town of <br /> IIL Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑New System 77,ep-lacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑Permit Renew ❑Permit Revi ton El Change of Plumber ❑Permit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration' �' Owner <br /> IV.Type of POWTS S stem/Com onentlDevice: Check all that apply) <br /> oNon-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 Rate(gpdst) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> a o , 7 Jr,/-/ /s"a 9� <br /> VI.Tank Info "{, I gappci, Total #of Manufacturer <br /> Gallon Gallons Units a <br /> v O U <br /> New Tanks Existing Tanks <br /> A <br /> septic or f ©�D C7 �' LCA e-S C o <br /> Dosing Chamber <br /> VIL Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plum s Si store MPIMPRS Number Business Phone Number <br /> WADE RUFSHOLM p. 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX 514,SIItEN,WI 54872 <br /> VIIL Coun /De artment Use On <br /> Permit Fee Date Issued Issuing Agent Signatur <br /> Approved ❑Disapproved I p <br /> ❑O'ivner Given Reason fdlbenial $3 7.5 • <br /> IX.Conditions of Approval/Reasons for Disapproval M <br /> 0�6 <br /> Attach to complete plans for the system and submit to the County only on paper not less thm alit es in size <br /> 13UIRIVETTCOUNTY <br />