Laserfiche WebLink
.. County <br /> Safety and Buildings DivisionPc-Wide <br /> aWashington Ave <br /> 1400 E Sanitary Permit Number(to be filled in by Co.) <br /> �5 <br /> ',' N P • P.O.Box 7162 3R.��I-- 33-7 ‘40G75 <br /> f Madison,WI 53707-7162 <br /> c -r-a, -_268 <br /> Sanitary Permit Application State Transaction Number <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. I-Ad , 7 <br /> I. Application Information-Please Print All Information / / / <br /> Property Owner' Name ( ( Parcel# t'f 7 O.j a 0. Ill /6 „?S/ <br /> ,eCIr1- , , ki.rE) .5 i5" aS6 c15'000 22.a <br /> Property Owner's Mailing Address Property Location <br /> (94/V3 lee r 0t.J e ro55"rJ 5 Rol Govt.Lot <br /> City,State L Zip Code Phone Number y, /<, Section <br /> tiAie c di/ mit), 5,5-0C 3 763`.2yy-6 5 65, //(circle one <br /> a� T 9/ N; R /b E t <br /> II.Type of Budding ding(check all that app➢y) Lot# <br /> PAI, ),r 2 Family Dwelling-Number of Bedrooms e2 ,S Subdivision Name <br /> Block# G r/ (-F ,4-c e' S <br /> — <br /> 0 Public/Commercial-Describe Use <br /> -..------ ❑City of �^ <br /> ❑State Owned-Describe Use CSM Number 0 Village of <br /> 'ownof S'/s-5 <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. hew System 0 Replacement System 0 Treatment/HoldingTank Replacement Only Other Modification to ExistingSystem(explain) <br /> B• ❑ Permit Renewal 0 Permit Revision ❑ Change of Plumber IDPermit 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 /> fir-Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade 0 Mound>24 in.of suitable soil 0 Mound<24 in.of suitable soil <br /> ❑ Holding Tank 0 Other Dispersal Component(explain) 0 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 /> Sod / 7 y 9 4/6–e) 9Z, r <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units 4.) <br /> o'b .0 <br /> New Tanks Existing Tanks w o B y a m <br /> a, c..) , rn wD 0, <br /> Septic or Fieldtrtg'Tank /OD CJ' -�— /c,a) / 41 o""e..1 e,5 c-O <br /> Dosing Chamber <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 Signat tie _........r.„_ <br /> "`-.- 227691 S Number Business Phone Number <br /> WADE RUFSHOLM l//l// 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 <br /> VIII.County/Department Use Only <br /> Approved ❑ Disapproved Permit Fec 4262 Date Issued Issuin ge Signa/ 01(/ <br /> ❑ Owner Given Reason for Denial $11 96 11//6/?/ ' / ' <br /> IX.Conditions of Approval/Reasons for Disapproval i%. le( 1� �' .25- <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 i7\lECElltel <br /> dies• 1 5 2C2 I <br /> SBD-6398(80313) - ' urnett County <br /> Land Services Department <br />