Laserfiche WebLink
(...J/ -/d <br />ice— Tv} <br />Safety and Buildings Division <br />County <br />q (( 0 `-'; <br />a! S ' 1= <br />1400 E Washington Ave <br />P.O. Box 7162 <br />Sanitary Permit Number to be filled in by Co.) <br />P <br />S <br />`' <br />V_�{ <br />.``. <br />Madison, WI 53707-7162 <br />oar a <br />Sanitary Permit Application <br />State Transaction Number <br />/V,4 <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 />purposes in accordance with the Privacy Law, s_ 15.04(1)(m), Stats. <br />10 3 5— �1allee J Ai <br />Parcel # o -7_ ©/ ;,Z-3 _3.3" <br />L Application Information - Please Print All Information <br />Property Owner's Name <br />l <br />P <br />6/- <br />Property Owner's Mailing Address <br />Property Location <br />T O O <br />Govt Lot <br />y. /. Section <br />City, State <br />Phone Number <br />/Zip <br />G�. <br />�Code 2 <br />5_7 g %J <br />�/ c� <br />" � o _ D 1 <br />(circl on <br />T�•N; R� <br />H. Type of Building (check all that apply) <br />Lot # <br />Subdivision Name <br />, 2 Family Dwelling -Number of Bedrooms <br />10or <br />Block # <br />11 City Of <br />❑ Public/Commercial - Describe Use <br />�- <br />❑State Owned -Describe Use <br />El Village of <br />i ITown of /n 6—:' PJ0k J <br />CSMNumber <br />—^ <br />iII. Type of Permit: (Check only one box on line A. Complete line B if applicable) <br />A. <br />KNew System <br />❑ Replacement System <br />❑ Treatment/Holding Tank Replacement Only <br />❑ Other Modification to Existing System (explain) <br />B. <br />❑ Permit Renewal <br />❑ Permit Revision <br />❑ Change of Plumber❑ <br />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 />1Non-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 (sf) <br />Dispersal Area Proposed (sf) <br />System Elevation <br />, -o <br />, S� <br />00 <br />av <br />VI. Tank Info <br />Capacity in <br />Total <br /># of Manufacturer <br />0 <br />Gallons <br />Gallons <br />Units „ ; <br />al U V <br />MN <br />New Tanks Existing Tanks <br />o i 2 <br />a U n <br />y _6 c° <br />rn is. 0 a <br />Septic or Haldir9aek <br />O <br />O <br />I /v z�') e C rj <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 />Plumber's Signature <br />MP/MPRS Number <br />Business Phone Number <br />WADE RUFSHOLM <br />` { `9 <br />(J�f oxo <br />227691 <br />715-349-7286 <br />Plumber's Address (Street, City, State, Zip Code) <br />PO BOX 514, SIREN, Wl 54872 <br />VIII. Coun /De artment Use Only <br />Approved <br />Disapproved <br />11$ <br />Permit FeeD <br />D <br />Date Issued <br />!/ Q� <br />Issuing Agent Signatur <br />ElOwner Given Reason for Denial <br />`-'2 7Sr <br />S 7 u <br />IX. Conditions of Approval//Reasons for Disapproval <br />�G <br />X119 PLG `OCATi0/1/ /Offal Div I" 9 aAJ) , r� E C E 0 V <br />Uv C e L /'/ 1,1X Ale � //� <br />Attach to complete plans for the system ano suomrc ro me a .-y uu.y uu Pal.o...o. 1 1 <br />:URNETT000NTY // <br />ZONING <br />