Laserfiche WebLink
Safety and Buildings Division Count nN/'NGn <br /> Y 0 201 W.Washington Ave., P.O. Box 7162 Sanitlm,,PermitNumber Bo be fled i—by Co.) <br /> Z' SP 1=1 Madison,Vol 53707-7162 <br /> S% 56653 4-1 <br /> 1 <br /> Sanitary Permit Application State TmnsadionNumber <br /> In accordance with SPS 383.21(2),Wit Adm.Code,submission of Nis form to the appropriate governments$unit <br /> is required prior to obtaining a sanitary permit Note Application forms for sNaoaaaned POWTS are submitted to Project Address(if different than tn Hmgaddress) <br /> the Department of Safety and Professional Servies. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privac Law,s. 15.04 I m,Stats. <br /> 1. Application Information-Please Print All Information <br /> Property Carter's Name Parcel4 B 7 O/ ..Z 6 , <br /> Krl3 ( #� a i 03 oboe) <br /> Property�Owner's <br /> /Mailing Address a Property Location <br /> S / C-,, e-4-e-1 41 Or. Lot `'GI <br /> City,State Zip Code Phone Number S'CJ y,, /OC 'G, Sectiones <br /> /,Jed 5 f e I -0:;5- SY8'93qq bratty no)_ <br /> If.Type of Building(check all that apply) Lot 4 I 7— R�Eo ' <br /> ?"'to 2 Family Dwelling-Number of Dedications 2- Subdivision Name <br /> Black# <br /> ❑Public/Commercial-Describe Use [I Ciry of <br /> Cl State Owned-Describe Use <br /> CSM Number D Village of <br /> PI'IUwn of 4't,) <br /> Ill.Type of Permit: (Check only one box on line A. Complete line B if applicable) _ <br /> OD <br /> A' ❑New System � lacemeat system D Tmam enUl lending Took Replacement Only D Other Modificarm to EarAirg System <br /> (explain) <br /> B. OPermit Renewal D Permit Revision <br /> ❑ ChrageoPlPemt Trawleft New <br /> .nerBerre Expiration anI,tst Pmvium l'urmit Number and Datc Issued <br /> IV.Type of POWTS System/Component/Devic,. Check all that apply) <br /> KNon-Pressurized In-Ground ❑ Pressurized In-Ground D At-Grade D Mound>24 in.ofsuitable soil D Mound<24 inof suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(cxpinin) D Pretreatment DcvieuPestilent) <br /> V.Dis ersal/Treatment Area Information: <br /> Design Plow(pit) Design Soil Application Rate(gpdsD Dispersal Area Required(s0 Dispersul Area Proposed(,0 System Llevatime <br /> 300 S' 97 <br /> VI.Tank Info Capacity is Total #of Manufacturer <br /> Gallons Gallons Units a C c _ <br /> New'fanks Existin,Too, `e v o <br /> c. <br /> Septic or l lMdwgTank <br /> Dasin,Chamber _Lo– s� ( C1 �. <br /> VII.Restated bility Statement- 1,the undersigned assume rc,purnibilit,far installation of the PUNTS shown on the attached plans. <br /> Potomac's Name(Print) Plumber's Signatur MP/MPRS Number I Business Phare Number <br /> WADE RUFSHOLM r /� 22)691 ]IS-949-Y2,6 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX 514,SIREN,W) 54872 <br /> VIII.Count /De artment Use Only <br /> pproved ❑ Disapproved I'emt�il Fec Data Issued Issuin nt ignatur <br /> ❑ Owner Given Reason for Denial $ J�� ol6l.3 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Amain to complete plans for the system and submit to the County oNh an parer not leu than 8 to t D Inma In site <br />