Laserfiche WebLink
r, —A, " County <br /> °t� \ <br /> I Safety and Buildings Division <br /> 0 1400 E Washington Ave Sanitary Permit be (to be filled in by Co.) <br /> �t p S P.O. Box 7162 r'�Q�7L1a <br /> \\ Madison,WI 53707-7162 <br /> Sanitary Permit Application State Transact ton Number <br /> In accordance with SPS 383.21(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 r <br /> purposes in accordance with the PrivacyLaw,s.15.04(1)m,Stats. l � -5 t <br /> L Application Information-Please Print All Information 3 <br /> Propertywner'S;Name Parcel# D 7 p V0 o_2 3$ <br /> 5 �/ c-3� ao2 G�50 Ol 6Ur`� <br /> Properly Owner's Mailing Address Property Location <br /> Govt.Lot <br /> City,State /— Lip Code Phone Number /t 1 &J y, Section <br /> 5o//I e.r!"5 t T �J` L L���5' (circle one <br /> H.Type of Building(check all that apply) ✓� Lot# T �N; R _E or <br /> �4z 2 Family Dwelling—Number of Bedrooms Subdivision Name <br /> Block# —� <br /> ❑Public/Commercial—Describe Use 1 — ❑ City of —� <br /> ❑State Owned—Describe Use CSM Number 11Village of <br /> i ! " *Town of <br /> II1.Type of Permit: (Check only one box online A. Complete line B if applicable) <br /> A' ❑New System ❑Replacement System Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑Permit Revision ❑ Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/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.Dis ersa[tTrestment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> o d v <br /> Gallons Gallons Units <br /> New Tanks Existing Tanks M ;; Y <br /> w U rA w C7 cA. <br /> Septic orHekhis& >aIK <br /> Dosing Chamber <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) i.,, _i Plumber'9 Signaler MP/MPRS Number Business Phone Number <br /> WADE RUFSHOLM y 227691 715-349-7286 <br /> Piumber's Address(Street,City,State,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 <br /> VIII.Court /De artment Use Only <br /> Permit Fee Date Issued Issuing Agent Signature <br /> ❑Approved ❑ Disapproved $ <br /> ❑ Owner Given Reason for Denial <br /> IX.Conditions of ApprovaUReasons for Disapproval <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 in x I I inches in size <br /> I <br />