Laserfiche WebLink
r�sr`r <br />Safety and Buildings Division <br />County <br />ON VOMPUTER/SCANNE p 1400 E Washington Ave <br />Sanitary Permit Number (to be filled in by Co.) <br />P.O. Box 7162 <br />SA ry - 1 $ -a (o <br />Madison, WI 53707-7162 <br />(pd a -%a % <br />sro�a�� - /S <br />Sanitary Permit Application <br />State Tr, /I/. -on Number <br />In accordance with SPS 38321,(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 <br />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 />f 567C <br />! � <br />purposes in accordance with the Privacy Law, s. 15.04(1)(m), Stats. <br />2 <br />Parcel # O 7 0 a J <br />U-% <br />L Application Information - Please Print All Information <br />erty Owner's Name f <br />P0T-(-e-(,j <br />Tf <br />/3©c�c� <br />e (,j l <br />., r/- r 0c,- ,P <br />Property Owner's Mailing Address n <br />r <br />Property Location "D c- <br />a b 2 C� /�cJ� ], ( F✓ <br />Govt Lot <br />,-; <br />IVE- f �/„ % L� I '/. Section <br />Y <br />State <br />Zip Code <br />Phone Number <br />City, <br />a)-�- <br />-5-'l n/ 3 <br />777 - el 9 <br />-T' <br />N. R /'? rclEone <br />` <br />U. Type of Building (check all that apply) <br />/ <br />Lot # <br />Subdivision Name <br />or 2 Family Dwelling - Number of Bedrooms <br />Block # <br />❑ City of �! <br />❑ Public/Commercial - Describe Use <br />❑ State Owned - Describe Use <br />❑ Village of -^ <br />CSM Number <br />j2r-'lbwn o£ G�,. <br />III. Type of )Permit: (Check only one box on line A. Complete line B if applicable) <br />A. <br />V New System <br />❑ Replacement System <br />❑ TreatmentlHolding 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 of POWTS S stem/Com onent/Device: Check all that apply) <br />XNon-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/Treat ent 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 />I <br />I <br />V1. Tank Info <br />Capacity in <br />Total <br /># of Manufacturer <br />Gallons <br />Gallons <br />Units S, U <br />A <br />New Tanks Existing Tanks <br />o <br />a U n va is. C7 P. <br />Septic or HoldilITTvak <br />/ Q Q `-� <br />G'� <br />�T i 4." S c <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 />227691 <br />715-349-7286 <br />Plumber's Address (Street, City, State, Zip Code) <br />PO BOX 514, SIREN, WI 54872 <br />. Coun /De artment Use Only <br />AApproved <br />I ❑ Disapproved <br />Permit Fee m <br />Date Issued <br />Issuing Agent Signature <br />El Owner Given Reason£or Denial <br />LX. Conditions of ApprovaVReasons or Disapproval <br />Z7E, W,� <br />do �/PGGo,� <br />• p IE <br />np <br />L4/�A lee <br />y <br />Attach to complete plans for the system and submit to the Uounty only on paper not Hess man a vz x tr mcnesp� �9rIH T u ZuluLO <br />6URNETT COUNTY <br />ZONING <br />