Laserfiche WebLink
=>?� Safety and Buildings Division <br />County <br />1400 E Washington Ave <br /><>/ S <br />Sanitary Permit Number (to be filled in by Co.) <br />. �. 1= P_O. Box 7162 <br />S <br />N <br />/'' Madison, WI 53707-7162 <br />o�s <br />S­iilYI✓= t,aa11a <br />Sanitary Permit Application <br />State Transaction Number <br />In accordance with SPS 38321(2), Wis. Adm. Code, submission of this form to the appropriate governmental unit <br />Note: Application forms for state-owned POWTS are submitted to <br />Project Address (if different than mailing address) <br />is required prior to obtaining a sanitary permit <br />the Department of Safety and Professional Services. Personal information you provide may be used for secondary <br />_ <br />purposes in accordance with the Privacy Law, s. 15.04(1 m), Stats. <br />7T <br />Parcel # d T d <br />L A plication Information — Please ]Print All Information <br />Property Owner's Name <br />( <br />Property Owner's Mailing Address <br />Property Location <br />O / 7 -?ft' / GtJ <br />Govt Lot <br />C. p '/. C' yg Section <br />City, State <br />Zip Code <br />Phone Number <br />f/� : //�� % ` <br />� <br />�� ' ! <br />(circle one <br />�� `^ <br />1� V / V <br />7 <br />T G� N; R /57 E o�W� <br />H. Type of Building (check all that apply) <br />Lot # <br />Subdivision Name <br />�1 or 2 Family Dwelling—Number of Bedrooms <br />Block # <br />❑ City of <br />ElPublic/Commercial — Describe Use rs <br />-- <br />❑ State Owned — Describe Use <br />El village of _r--- <br />`Town of <br />CSM Number <br />--- <br />III. 'Type of Permit: (Check only one box on line A. Complete line B if applicable) <br />A. <br />P .New Systemp <br />❑ Replacement System <br />y <br />❑ Treatiment/Holdin Tank Replacement Only <br />g P Y <br />Other Modification to Existing System (explain) <br />B <br />El Permit Renewal <br />❑ Revision <br />❑Change o£ Plumber <br />El Permit Transfer to New <br />List Previous Permit Number and Date Issued <br />Before Expiration <br />Owner <br />IV. Type <br />of POWTS S stem/Com onent/Device: 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) <br />Design Soil Application Rate(gpdsf) <br />Dispersal Area Required (st) <br />Dispersal Area Proposed (sf) <br />System Elevation <br />VI. Tank Info <br />Capacity in <br />Total # of Manufacturer y <br />o <br />Gallons <br />Gallons Units L <br />2 <br />New Tanks Existing Tanks <br />d o <br />a v <br />rn y <br />v <br />re i� C7 a <br />6epde er Holding Tank%G�c�(Ft <br />(D - <br />Dosing Chamber <br />VII. Responsibility Statement- 1, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. <br />Plumber's Name (Print) <br />WADE RUFSHOLMf <br />Plumber's Signature <br />r /yam <br />C•t/ 2C�' <br />MP/MPRS Number <br />227691 <br />Business Phone Number <br />715-349-7286 <br />Plumber's Address (Street, City, State, Zip Code) <br />PO BOX 514, SIREN, WI 54872 <br />II. County/Department Use Only <br />Approved <br />11 Disapproved <br />Permit Fee <br />_ <br />$ <br />Date Issued <br />Issuing Agen Sign <br />El Owner Given Reason for Denial <br />7`S ` <br />I / Q <br />�i f0 1V' <br />IX. Conditions of Approval/Reasons for Disapproval �% / �� ,► / / <br />/ ' / # /' / !J(NL / / if � S i S Alala* <br />�a <br />G�"/���/Vpt /5 f"D/' SY21%A�P/GQ.✓�A.l�'e/j <br />US's .�S�ay� <br />/ <br />GGD /� ����1�if� <br />/Uo>l -/. �� l�J�� or f{v�ati�a6/�ao�v?a�i^o0�ns 4Ve <br />nQ <br />Attach to complete plans for the system and submit to the County only on paper not less than 8 v2 x inc <br />in RR <br />2018 <br />BURNETT COUNTYr <br />ZONINr, <br />