Laserfiche WebLink
brti ji' r County <br /> 1 Safety and Buildings Division <br /> 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.)$Is P.O. Box 7162 <br /> e .Y / Madison,WI 53707-7162 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS X83.21(2),Wis.Adm Code,submission of this form to the appropriate governmental unit <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 of Safety and Professional Services. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s. 15.04 I m,Stats. <br /> I. Application Information Please Print All Information <br /> Property Owner's Name Parcel# Q 7p r,2Z J <br /> 01 —/� /' S c`35� <br /> Property YOwner's Mailing Address <br /> Property Location <br /> / C� <br /> / y J Govt.Lot_/ <br /> City,State Zip Code t� Phone Number 1/4, y., Section <br /> �e t� 5 Z�/3 ( ircle one) <br /> IT. <br /> Type of Building(check all that apply) Lot# T N; R E or W <br /> Il Al or2Family Dwelling—Number ofBedrooms 2 Subdivision Name <br /> ✓ z_ - Block <br /> ❑Public/Commercial—Describe Use El city of r---- <br /> �— <br /> Ll State Number El Village of State Owned—Describe Use Y7 _ <br /> own of S G a <br /> 1 . f'l' <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' ❑ New System placement System ❑ Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑ Permit Revision 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 System/Component/Device: Check all that ap 1 <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 Rate(gpdst) Dispersal Area Required(0) Dispersal Area Proposed(sf) System Elevation <br /> VL Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units p o g <br /> New Tanks Existing Tanks m Pd <br /> cCU � y v, wC7 a <br /> Septic or R"IdngT'eek <br /> Dosing Chamber ,_ 5-0 <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> WADE RUFSHOLM / 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 <br /> Vlll.County/Department Use Only <br /> Approved ❑ Disapproved Permit FeeD Date Issued Issuing Agent Si <br /> ❑ Owner Given Reason for Denial $ 19c, <br /> 7 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 in x 11 inches in size <br />