Laserfiche WebLink
County <br /> Safety and Buildings Division ^µ)e- <br /> 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> j 4 i P.O.Box 7162 <br /> L Madison,W 153707-7162 <br /> A <br /> Sanitary Permit Application State Transaction Number <br /> 1n 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 hailing 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. <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name / Parcel#D '1 cr./ a 3 cY 6 ar <br /> r l� oje-,okk /, Jl <br /> Property Owner's Mailing Address l Property Location <br /> t // / /� <br /> 7 /U �` s KC 4 �� `�• Govt.Lot <br /> City,State Zip Code Phone Number y, %, Section <br /> -5/117 O circle one) <br /> T N; R 1 EorW <br /> � II.'Type of Building(check all that apply) Lot# <br /> 1 a or 2 Family Dwelling—Number of Bedrooms Subdivision Name <br /> i <br /> Block# <br /> n Pubiic/Commercial-Describe Use ❑ City of <br /> r CSM Number ❑ Village of <br /> J State Owned-Describe Use <br /> .— -Town of�j'l�1`P�/c.J f7/✓ <br /> I <br /> III.'hype of Permit: (Check only one box on line A. Complete line B if applicable) <br /> New System y Y"' p y ❑ Treatment/Holding Tank Replacement Only El Other Modification to Existing System(explain) <br /> I � ❑ a placement System <br /> B. ❑ Permit Renewal ❑Permit Revision ElChange of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV. t e of POW'I'S System/Component/Device: (Check all that apply) <br /> ?on-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.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 3ae� / 7 <br /> 17I.'Tank Info Capacity in Total #of Manufacturer Y <br /> Gallons Gallons Units n ;15 U <br /> New Tanks Existing Tanks 2 o L �J cc <br /> a. U � rn R a, <br /> h`1 1 cn C7 <br /> Septic or Wo ag-Tal& 000 �,.'/'C.1 &)e!,S e:0 <br /> ---------------H--------------- <br /> Dosing Chamber <br /> VII.Responsibility Statement- ➢,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 /. 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) ( / <br /> PO BOX 514,SIREN,WI 54872 <br /> 11111.Co11n /HDe artr11eY1t Use Only <br /> Approved ❑Disapproved Permit Fee Date Issued Issuing Agent Signature <br /> ❑ Owner Given Reason for Denial $ 3�s -z- <br /> I .Conditions of Approval/Reasons for Disapproval <br /> i EcE0YE <br /> � D <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 1 i 11 <br /> es inn R U 1 2r4l <br /> SP,D-6398(R0313) hHi <br /> urnett County <br /> Land Services Department <br />