Laserfiche WebLink
County <br /> Safety and Buildings Division l� C4" LT! <br /> J� <br /> 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> r ��! P.O.Box 7162 <br /> "^ Madison,WI 53707-7162 <br /> Sanitary Permit Application State Transaction Number 63-7 <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 Df different than mailing address) <br /> the Department of Safety and Professional Services. Personal information you provide may be used for secondary 3/30j <br /> purposes in accordance with the Privacy Law,s.15.0 1 m,Slats. <br /> L Application Information—]Please Print All Information <br /> Property Owner's Name Parcel# p`7 403;Z 47 97 / D 27 <br /> C &"/es kl ev.v A Tr N.S--f <br /> Property Owner's Mailing Address Property Location .,-J -41:412 <br /> g S� 17/ Co ere' L.00 <br /> Gout.Lot <br /> !-(Ci/ry,,S�s:af�e Zip Code Phone Number <br /> y,, %<, Section <br /> Yc T 7-070 e�� �ircle on <br /> ;lII. II ype of IIIIaai ding(check all that apply) Lot# T- 1=—N; R /S E o a/ <br /> 15- or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block# <br /> j ❑Pu'olic/Commercial-Describe Use <br /> ❑ City of <br /> CSM Number Vill❑ of <br /> State Owned-Describe Use age <br /> 1// / / �1'own of SW <br /> i V <br /> III.Type of Permit: (Check only one box on line A. Complete line 1B if applicable) <br /> A' ❑New System Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> ? List Previous Permit Number and Date Issued <br /> T• u Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New <br /> Before Expiration Owner <br /> Pi.Type of POWII'S System/Component/Device: (Check all that a 1 <br /> ! %N.n-Pressurized In-Ground ❑ Pressurized in-Ground ❑ At-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> i Li i oiding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> i V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> /5 d 1 d:p _ IiZS`o <br /> I VL'l'anik Info Capacity in Total #of Manufacturer <br /> j Gallons Gallons Units " 5,20 <br /> Ncw Tanks Existing Tanks o 2 0 5 <br /> I �+j Septic or Heltliug�aa{ct <br /> Dosing Chamber <br /> i <br /> VIII.Responsibility Statement-1,the undersigned,assume responsibility for installation of the POWI'S shown on the attached plans. <br /> i Plumber's Name(print) Plumber's S'gnatur MP/MPRS Number Business Phone Number <br /> jWADE RUFSHOLM /./ 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 <br /> I <br /> VM.Comm /_Department Use Only <br /> I ❑Approved ❑Disapproved Permit Fee DatgJssued 1 g gnat <br /> Z I El Owner Given Reason for Denial $ 1 /u ' <br /> I IX.Conditions of Approval/Reasons for Disapproval <br /> a <br /> 9=3 C E 0 Y E <br /> l <br /> i <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 iAW6 ilk <br /> SBD-si398(R0313) <br /> umett County <br /> Land Services Department <br />