Laserfiche WebLink
-}� <br /> I Cow Safety and Buildings Division q,^ d 2,// <br /> ' p 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> P.O. Box 7162 n <br /> L`SP SIof Madison,WI 53707-7162 - /3S-'3 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance wit SPS 383.21(2),W is.Adm.Code,submission of this form to the appropriate governmental unit <br /> is required prior w obtaining a sanitary permit' None:Application fumes for shoseowrcd POWTS erre submitted to Pmjan Address(if diftereat does mailing addres) <br /> the Department of Safety and Professional Services. personal information you provide may be used for sccundary 1 <br /> purposes,in accordance with the Priv law,s.15.04 1 m,S . 7Vqn/l O//N <br /> I. Application Information-Please Print All Information <br /> P7 0. 's Name Parcel#p 7 O/ `iZ / <br /> S O000 6 /a0d <br /> ropoJy Owner's Mailing Address /,/1 Property Location/G <br /> /N O Govt.Lot <br /> City,State// II .l I I., %ip[C/uodie Phone <br /> Number Q / 5'E o. ,/A, Section /� <br /> .f�-N: R-/4 r. <br /> rresa.Type of Building(check all that apply) /' Lot# <br /> ry for 2l'amily Dwelling-Number of Bedrooms LJ/frfj-$.= / Subdivision Name <br /> PQ/� f`QU Blacks <br /> U PublicaCommaend-IMcribe Use ❑City of <br /> CSM Number Cl Villageul' '— <br /> ❑State Owned-Describe U. /N ) <br /> — Town of G.�ItJ' c9N <br /> III.Type of Permit (Check only one boa on line A. Complete line B if applicable) <br /> A' P-N'.S'win U Replacement System 11Treatmen/11.1ding'1'ank Replaeement Only U Other Modification to hoisting System(explain) <br /> B. U Permit Ren.,.1 U Permit Revision U Change of Plumber U 1'crmit Transfer m Ncw List Reviouu IMonit Number and Daae Issued <br /> Before Expimlinn Own <br /> IV.Tone of POWYS S stem/Com onent/Device: lChneck all that apply) <br /> U Nan-Pressurized In{irowd U Pressurized In-0mund U At-Grade U Mm nd 124 in.of suitable mil U Mound<24 in.of suitable sail <br /> XHolding'1'ank U Other Dispersal Component(explain) U Retreatment Ikvlce(explain) <br /> V.D scirmal/frestmant Area Information: <br /> Design Plow(gpd) Dr ign Soil Application Itatch rod 0 Dispersal Area Required(s) Dispersal Area Proposed bi S)sman Elevation <br /> /50 --- <br /> VI.Tank Info Capacity in Total #of Manufacturer r <br /> Gallons Gallons Units s 9 Y <br /> New Tmks Caisting TaN3 2 2 y x u <br /> iU -U <br /> sYwm Bnlyng T. �1_oDo a00 G <br /> Dosing Climber P <br /> VII.Responsibility Statement- 1,the uedenigncd,mama rcapa.aibifiry for imtalhdun of the POWTS show.o.the aB¢hed ... <br /> Plumber's Name(PJnQ Plum 's Sao=. MP/MPRS Number Business Phone Number <br /> WADE RUFSHOLM / 227691 115-349-7286 <br /> Plumber's Address(S(.L City,State,Zip Code) �✓J <br /> M BOX 514,SIREN,WI 54872 <br /> VIII.County/De artment Use Ord <br /> Permit Pcc Uetc Issued Issuing Agan Signature <br /> pprovcd Cl Disapproved S � <br /> U Owna Given Reason fon Ihninl ( � ��'� 'r <br /> IX.Conditions.(Approval/Reasons for Disapproval �� 1j=1 Imo+ <br /> we'll .f"s F be >26-4 �� /r T � ,� I[ <br /> 4 RU q <br /> OCT 2'S 2014 <br /> Anvchtemmpon,Plam for the sYiona a ad.wbmit to the County only on paper not lm than airs z l mBURNETT COUNTY <br /> — ZONING <br />