Laserfiche WebLink
..JLpxRi►tk'' County <br /> l'` g Safety and Buildings Division <br /> I Q � 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> PSI P.O. Box 7162 <br /> :r Madison,WI 53707-7162 kE�+ <br /> f � <br /> % <br /> Sanitary Permit Application State Transaction\umber lJ <br /> In accordance with SPS 383.21(2). Wis. Aden. Code, submission of this form to the appropriate governmental r <br /> unit is required prior to obtaining a sanitary permit. Note: Application forms fur state-owner! P01YTS are Project Address(if different than mailing address) <br /> submined to the Department of Safety and Professional Services, Personal information you provide may be <br /> used for secondary pyrposes in accordance with the Privacy Law,s. 15.04(l)(m).Stats. , <br /> 1. Application Information-F'Iease Print Alt [nformation W. <br /> property Owner's Name Parcel q <br /> fr'�` 07-Do�r1-�3,-40-lfv- <br /> 3loS 5S-3 <br /> Pmpeny Owner's Ma iling Address Property Location <br /> xamCc I r Govi. Lot <br /> Ci ,State Zip Cixk Phone Number �k,SUL 16,Section <br /> V� (circle ope) <br /> 11 Type of Ruildi check all that apply) v Lot N T � N k L <br /> amily Dwelling-Number of Bedr(x)ms P\ C Subdivision Name <br /> Muck N <br /> ❑PubliclCoounerciat-Ascribe Use <br /> ❑ City of <br /> ❑$rate Owned-fkscribe Use <br /> CSti1 Number ❑ Village of <br /> own of <br /> -.g- <br /> III. Ty •of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A 1/k";Cw System <br /> y ❑ Replacement System ❑TrratmendHnlding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> a. f Permit Renewal ❑ Permit Revision ❑ Change of ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Fxpiration Plumber Owner <br /> �5-�E 1U-7-r <br /> IV. Ty of PMV17S Systern/Com vent/Device: (Check all that a 1 <br /> ❑ Von-Pressurized In-Ground Cl Pressurized In-Ground ❑ At-Grade ound 7 24 in.of suitable soil ❑ Mound C 24 in.of suitable soil <br /> ❑ Ilulding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V. Dis rsal/'1'reatment Area Information: <br /> Design Flow(gpd) Design SoiI ApplLLication Rate(gptisI) Dispersal Area Required(sf) Dispersal Area Proposed(if) System Elevation <br /> •�J <br /> V1. Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units G _' <br /> a J v <br /> \css TanksUsting Tzrtks L <br /> Septic or Ifolding Tank Iwo 4— <br /> gy(y1 <br /> I kisi ng Chamtwr CN ll <br /> N'I1. Responsibility Statement- 1,the undersigned,assume responsibilit• or installation of the PO1A TS shown on the attached plans. <br /> Plumber's Name(Prin i) Plumhcr' Signa rule 011MP/MPRS Number Business Phone Number <br /> WADE RUPSIIOLM _ O 227091 715.344-7286 <br /> Plumber's Address(Street .City,State,Zip Ccxie) <br /> PO BOX 514.SIREN,WI 54872 <br /> VI .CountylDe artment Use Only <br /> proved ❑ Disapproved Permit Pee Date Issued{ Issuing`gent Si nature <br /> ❑ Owner Given Reason for Denial $ � n re <br /> IN.Conditions of Approval/Reasons for Disapproval <br /> 44 1 OCT # 2013 <br /> e(n)+ Rp4at �X-pi res 1 -"`�t" COUNTY <br /> Attach to compteuk plans for the sjs1eVn and suhmft to the County onlV un paper not lees than S 1 t 6yz�w'r± <br /> SBD-6398(R0313) ry11`tLa <br />