Laserfiche WebLink
y,£PART.y�Y County <br /> Safety and Buildings Division <br /> 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> f P I P.O. Box , �h_7� <br /> Madison,WI 53707707—7162 �l-� /`�)�� <br /> \ any1 F- _s �f V/' <br /> Sanitary Permit Application State TransactionN ber <br /> In accordance with SPS 38321(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit .ec6z 74-10 <br /> is required prior to obtaining a sanitary permit. Note:Application forms for state-owned POWTS are submitted to Project Address(if different thanmaiaddress) <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 t <br /> m,Stats. vt ^G/ ,k <br /> I. A l Application Information-Please Print All Information /r <br /> Property owner's f4ame �y Parcel# 7 o VO 3 9 ! 9a-,z <br /> Cao / 000 <br /> Property <br /> Oww{nces Mailing Address _ Property Location <br /> Govt.Lot <br /> City,state o Zip Code Phone Number / p / e y, O ��.� Section�r,�a, <br /> C,0 <br /> �u.`6/ 77 i1G� A�. 5 5y�� &13--,;113-1 0 6 7 T 3�N; R 1�(circle one) <br /> E or(D <br /> II.Type of Building(check all that apply) Lot# <br /> or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑ village of r y�-- <br /> yTown of W., /AJ <br /> I11.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. New System ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑Change of Plumber ❑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 e I <br /> ❑Non-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(gpdst) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 1 Z15-0 1 Y <br /> VI.Tank Info Capacity in Total #of Manufacturer N c <br /> Gallons Gallons Units V y <br /> New Tanks Existing Tanks <br /> R. U VJ N rA k. •./ O+ <br /> septic or HeWs sAwik- <br /> Dosing Chamber <br /> VII.Responsibility Statement-,11,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plum er's Signature 227691 S Number Business Phone Number <br /> WADE RUFSHOLM c�l�/✓ 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 <br /> VIII.Coun !De artment Use Only <br /> Permit Fee Date Issued Issuing Age 'gnatu <br /> Approved ❑ Disapproved 2-7 <br /> ❑Owner Given Reason for Denial J $1 /�` �a�! <br /> IX.Conditions of ApprovalfReasons for Disapproval TJUN <br /> R2015 <br /> Attach to complete pleas for the system and submit to the County only on paper not less than S tR z 1OUNTY <br /> ZONING <br />