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HomeMy WebLinkAbout024-641-13-3402-SAN-2022-106 � . � � SAWYER COUNTY ZONING & CONSERVATION ADMINISTRATION , � 10610 Main Street, Suite 49 Hayward,Wisconsin 54843 �4 (715) 634-8288 G sanitarian(a sawvcrcount���o��.org � COUNTY SANITARY PERMIT APPLICATION In accord with Chapter DSPS 383,Wis.Adm Code and Sawyer County Private Sewage System Ordinance APPLICATION INFORMATION—TYPE OR PRINT Property Owner's Name Property Legal Description ��� -� s c..��� GL s� Ya S(C,� Y4, Sec. %,3 ,Twp.�N, Range _(y_W Propr�rty Owner's Mailing Address Lot Number Block Number t�-G . �cX zi � Cit State Zi Code Phone Number Subdivision Name or CSM Number �� '�t.r� �� S`��'f 3 � 7�i� 4�3�sZf// Zo ys� #S�S3 TYPE OF BUILDING: (Check one) ❑ State Owned ❑Ciry tve sr xoad ❑ Public �1 or 2 Family Dwelling—No. of bedrooms� �Village ;� i '� ���'�1�� �Town of ltCli,y�(� �G:� Fire I`umber !�� � PUBL[C BUILDING/LAND USE: [Explain the use/purpose forthis Parcel Tax Number: (12 digit legacy number) permit,(i.e.,campground,festival,recreation/entertainment event etc.)] ��s,c��ti{-�ii( 0 �� �-_ le � /_� 3 _� � v L TYPE OF PERMIT: Additional Information: ❑ POWTS Reconnection(SAN#_- ) � POWTS Connection (SAN# ' *Attach a Plot Plan with all required information per SPS 383.21 [�j POWTS Revision(SAN#�2-� ❑ POWTS�Re�p�ir(SAN#_� *Soil Test Information(CST#L� - (J � ❑ Other: al��G R K �P' Pt�U,.,O '���. T *Gallons per day `b� RESPONSIBILITY STATEMENT: I,the undersigned,assume responsibility for the installation of the POWTS activity for which this permit is issued. Plumber's Name:(Print) Plumber's Si MP/�A�F�S��o: Business Phone Number: ��s��� l.Cu�f-��i ��-�S�S7 ( �cd' � -3j5 _ `�lumber's Address(Street,Ciry State,Zip Code): -� . � �c�O� t,�..L 2/ OFFICE USE ONLY: ❑Disapproved Review Date: ermit Fee: Date Issued: Issuin�Agent Signature �Approved ❑Owner Given Reason for / [� ( /� , ` Denial b � � J v.�� � I�5 �� � I.!'��,u�C l ,�-,-pD— COMMENTS: **Expires 2 years from date of issue** Expiration date: �9� � .s l:���-f CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: � � ��ALI� � � � Gs� � � �- o�� JUN 1 3 2022 � �I IN C A� �.��h.���rvr���t���,���°�° ,,�.- �. �,-�� Rev.04/21/15 NO REFUNDS AFTER ISSUE OF PEAMIT �.�. owner : Le • : /1 �, p 1 T . ObleT J� SG�etrTNS� 50.w�C`�' �-[J •� 1\OJ✓�,C L4� b�a.t j� �0 Bx Z �P�nl: OLy_ 64 (- 13 - 34oz � f-�0..�wird,w ( sN843 SE�s�..� 5 i3 'T" �{!ti1 P� Obw Lo� � Cs M z o�as -"� S7 43 . F �' i�zr �° T +z� . rl�� }o scdle 4 i �� - No�- �� stk� � � �x\f��.G C_ `'2 ;� � 4 �11S --r ��`,\,`J�C� c,.` � � �\� ���? l� � u � �X�3T1.n1(� t�ICSt�'L/oon Z ���' c— l'_ 4�� O�7.L'NLc r i�lx:iZ T � �c- y..ac�. k �� � � ���� , . 3 o � ?� � � � �x � \ � �: � � o :,JC�h�� � \ c � � • J� � �,. ��- ��� � ���,t , \ ,,de, � �/� � i" S[a�e I"- 4a 68hto�� na�13o���� so5'.de zz"Ma�1e,w,�r�bEvh !i I . 9 6.8 ' � ,ab.bz� 3 . Qb.85� `�� 96.35� .S So, �� sc�sf• e�. 93.5 � �-� 5 T ih ± 95' s�5�. 3� X bo� E-Z�'lo�u Go��c� go bB�wu.-� _-- ', , . - 81,2,3 0� 1,3�4 . %,���� �;MP rc'75')S� I�e�el s; +c na Con�"o�S' s 5 /Z,�Z.,�Y L u.7e11 �'o m� co de s��.c��Gs