Laserfiche WebLink
•; a_17.,ri,,,:..f County <br /> Safety and Buildings Division 3,-e ^ 17 <br /> 1400 E Washington AveSanitary Permit Number(to be filled in by Co.) <br /> ' , C-tip 1' 1 P.O. Box 7162 5R.^f✓20✓�9 <br /> Madison,WI 53707-7162 <br /> ',',.;•;.:z., ,,lV__.�-... .-/ — 2c4 37 G31 1-2--(.1-2--(. <br /> State Transaction Number <br /> Sanitary Permit Application �, <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 <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. ,S A 'C-- <br /> II. Application Information-Please Print All Information <br /> Proer y Owner's Name Parcel# Glc O oZ '/O /�o �}1 <br /> h All) l�)7 r//^ �/ ,� 6)5 C'00 o//Only <br /> Property Owner's Mailing.A/d-dress Property Location /0 c-�/ #/3 2-5-7 <br /> by a ' c C Govt.Lot <br /> City,State / / Zip Code Phone Number / .,�G J '/<,/f)4-1.) /, Section %T <br /> 6 /c,ib q/ , Iv/ Y53 0 7/.5: 7r, 7i 1' i�11 / (circle one) <br /> I II.Type of BuildiT 7 d N; R l E o �L7 <br /> �r'yp g(check all that apply) Lot# <br /> 1 $4,-or 2 Family Dwelling-Number of Bedrooms .._..3 Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use ---- �_ <br /> 0 City of <br /> ❑State Owned-Describe Use `— CSM Number 0 Village of - <br /> %Town of 04 k//9'/)n <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑ New System Re lacement System y � p y ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. 0 Permit Renewal 0 Permit Revision 0 Change of Plumber 0 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 0 Mound>24 in.of suitable soil 0 Mound<24 in.of suitable soil <br /> 0 Holding Tank 0 Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Oication Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> Y5-4() 7vc) 79 -) 9y", s_ <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units „ °, 0 -0 0 <br /> New Tanks Existing Tanks w <br /> P. o , .Do 2 n. <br /> a U cn �, en 4. 0 a•1 <br /> Septic or HtridilS f k /ed C (/�L)�� /� �+��J�o , <br /> Dosing Chamber 7 <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> WADE RUFSHOLM /�C /`,�, <br /> ,f �. 227691 715-349-7286 <br /> !tiC <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 <br /> VIII.County/Department Use Only <br /> Permit Fee Date Issued Issuing Agent Signature <br /> '\ <br /> Approved ❑ Disapproved -3757.-- <br /> -7 <br /> CIJ'Owner Given Reason for Denial $ 5'' /1- 23.2'7) <br /> IX.Conditions of Approval/Reasons for Disapproval e4( 14'445- *-4,‘2,- <br /> D ECIEUVIE --J� <br /> Is <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 1 .1 i es ij�y, 2 0 2020 / <br /> SBD-6398(R0313) "J <br /> Burnett 66117— <br /> Land Services Department <br />