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HomeMy WebLinkAbout016-637-30-5403-SAN-2022-070 � SAWYER COUNTY ZONING & CONSERVATION ADMIN[STRATION � 10610 Main Street, Suite 49 � Hayward, Wisconsin 54843 N (715) 634-8288 � sanitarian�?r%sa���vercountti��ov.org � � COUNTY SANITARY PERMIT APPLICATION � In accord���ith Chaptcr DSPS 383. Vdis.Adm. Codc and Sa���yer Counl�� Pri��ate Sew�age S��stem Ordinance APPLICATION INFORMATION—TYPE OR PRINT Prop�rty O�nmer's Name � �� �1.. Proprm I.eeal Descri�on � � � � I Yl C�lirZ Gl, fi'vV 'i� �C '/�. Sec._3� .�fwp.� � N. Rangc 6 ._W Property Owner's Mailing Address � Lot Number Block Numher N S� 3 3 �-! � ��-t� Cit��.State Zip Code Phon�N�unber Subdn'ision Name or CSM Nwnher L.0.� ,S i �i ��� � �77.�> �7 7�— y�� � TYPE OF BUILDING: (Check one) ❑ State O���ned ❑���•� N��r�S� ��� � � _] �� ❑v�i i<� z �-+ ❑ Public [�I or 2 Famih U���elling—No.of bedrooms 2 � �e�� (�tc; i"c;�� E,rc Nu�„bcr - f��I�o«�n of PUBLIC BUILD►NC/LAND USE: ���plain d,c use/purposc for d�is Pareel Tax Number: (12 digit Icgac�� numbcr) penniL(i.e.caropground.festival.rccreation/entertainm�nt e��ent etc)� � � � 6-� �.7 -� Q-s `l G— TYPE OF PERMIT: Additional Information: � POWTS Reconnection(SAN # ���' �� ❑ POWTS Connection (SAN#_- ) *Attach a Nlot Plan with all required information per SPS 383.21 ❑ NOWTS Revision(SnN#_- ) ❑ POWTS Rep�ir(SAN#_- ) � *Soil Test Information(CST# ��7 �7/) �Other: �_G YD �� r e. - C O (`� �`� Q C.rt SG`� ?� g� � �3 S *Callons per day �00 �-� _ RESPONSIBILITY STATEMENT: I,the undersigned,assume responsibilin� �or the installation ot�thc POV�'TS acti��ih� for���hich this permit is issued. Plumber's Name:(Pn�w Plumh�' natur .A4f'IMPRS�1'No� [3usiness Phone Numher: �err J�� �`227/7i (7iy� Ss6fs 7Fs7S Plumbers Add ss(Street,Ciq�Statc.Zip Co��: w I �� 1 ' /� +ti� L , Q.w w� ` �'�7 S OFFICE USE ONLY: ❑Disapproved R�rie�c Datz- P�nnit I�ce- D�t�Issued� Issuin�necnt Signature �Ap o��ed ❑O�rner Gi��en R�ason for �� / �� ��,Qo l �,� �� 7�,�`�tii�"'"`-rt'�I� � Drnial , ` '��� COMM ENTS: **Expires 2 years from date of issue"* F.xpiration date: CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: �� � �� CS1 �� -- �JL �'�����_�����_:. '^' _ - � ��-� P�,�Y � s ?�22 --� ' � Rev.04/21 i 1� -- ---�---- S�=.i�'di'6���. ��,:_;�._�..,.,..; NO REfUNDS AFTER �p�iING ADtv�;iv;s��t���!oN , ISSUE OF PERMIT