Laserfiche WebLink
U�arary COWt)• �/ <br /> 'I a Safety and Buildings Division (- <br /> P (�0� 201 W.Washington Ave., P.O. Box 7162 Sanitary Ieanit Number na be filled in by Co.) <br /> Madison,WI 53707-7162 S'�x 558 992 F <br /> �P <br /> Sanitary Permit Application Swe'Ia "Nambo `y <br /> In acvardance with SPS 383 21(2),Wis.Adm.Code,submission ofmis tom in Ne appropriate governmental anis ulew <br /> s required prior to obtaining a sanitary permit. Note:Application bear,fontatc-owned POWTS are submitted to Project Addnss(if dilliscal Nan mailing address) <br /> the Iepartmem of Salbty and Pmfessional.envies. Personal information you provide maybe used lin secondary <br /> purposes in accordance with the Priec vaw,s_1504(l)m),Smrs. <br /> 1. Application Information—Please Print All Information 7920 e, KI[ <br /> Property Owner's Name / For.)a O 7-0s7 7. --4•yd-/ - <br /> x>] <br /> Prncem Owner's Mailing Address - _ 14openy Location de <br /> 41— <br /> a 7 0 C— Govt.Lot <br /> City,Stale !'peak Phare Number ]/!�f 1�E y,. Section <br /> e6 e/ t,) Yb % ; (oclemeLL <br /> IT.Ty pe of Building(check all that apply) Iaxa T N; R1�li ntJ <br /> II- t or 2 Family Dwelling—Number of ltednnms Subdivision Name <br /> � Block <br /> C1m <br /> PubbdComerewl—Desenk-Use /� <br /> 11 City of <br /> ❑State Owned—Dc enbe Use CSM Number 0village of <br /> Town of .J GO <br /> Ill.'I'ype of Permit: (Check only one box on line A. Complete line B ifapplicable) <br /> A. 0New System -Rcpincemenl Systcm ❑'l rwmenl/Holding Tack Replacement Only ❑Otho Mriificmion to Existing System(esplain) <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑Chelgeof Plumber ❑Permit Tranxfom New List Previous Permit Number aN One lssocd <br /> Before Expiration (honer <br /> IV.Type of POW FS Svstem/Com mnenUUcvice: Check all that split,) <br /> Q�Non-Pressurimd In-0mund ❑ pot smiu ti-0round ❑At{]mdc ❑Mound 124 in,of madde soil D Mound 124 inofsuimble mil <br /> ❑ I lolding Tank ❑Otho Dispersal Component(explain) ❑loc remmem Devitt(explain) <br /> V.Dis ersaVi'reatment Area Information: <br /> Design Flow(pd) Design Sail Apphemom Rahlgpd1B Dispersal Area Reclaimed(so Dispersal Arta P..poi(s0 System Elevation <br /> 0o ya 5�sa 6, <br /> VI.Tank Info Capacity m J�Alons <br /> k of ,Manufasurer <br /> Dollars Units tt <br /> New Talks Esem,Tnanks —(.JC <br /> Dosing Cavan., <br /> VII.Responsibility Statement- 1,the undefsigned-assume rxsponsibility for installation of the PON-IS shown an the mtachcd plans. <br /> Plumber's Stame(Prinn Plumber's Signmure MP/MPRS Nkirtmeal Eussome Number <br /> WADE RUFSHOLM ]IS-349-]286 <br /> Plumber's Address(Street,City,Stam,%ip Ctd.) <br /> 110 BOX 514,SIREN.WI 54872 <br /> Ed <br /> COuna <br /> 1V/De rtann t Use Onl <br /> rL Appmved ❑ DisapprovedI'crtnn Fa IMc Issued Issuin _ ret Signs <br /> S �/C <br /> ❑Owner Given Be..for Denial 3/.J ;0 11f. 13 <br /> PC Conditions of Approval/Reasons for Disapproval <br /> na.m a rumP4h plxm br mr ohn and maim,In ror ration.1,nn o.orr nm tew ra..8 In,11 Inehn in sbe <br />