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aazxgtr County _ <br /> ° ��Safety and Buildings Division <br /> 1400 E Washington Ave sanitary Permit Number(to be filled in by Co) <br /> P.O. Box7162 SAPJ 1 -7-03 <br /> l7'AgO�ssro SQ pf Madison,WI 53707 7162 <br /> 4 State Transaction`�Number` <br /> Sanitary Permit Application <br /> In accordance with SPS 39321(2),Wis.Aden.Code,submission of this fort to the appropriate governmental unit <br /> is required prior to obtaining a sanitary permit Note:Application forms for state-owned POWTS are submitted to Project Address(if different than mailing address) <br /> the Department of Safety and Professional Services. Personal information you provide may be used for secondary Q G/5� <br /> purposes in accordance with the Privacy Law,S.15-04(1 m Stats. <br /> L Application Information-)?lease Print All Information Parcel#�9 <br /> Property Owner's Name <br /> fJ00 <br /> Property Owner's Mailing Address Property Location G <br /> ya /WCA#e— Govt Lot <br /> City,State / Zip Cade Phone Number s GiJ y, /., Section�. <br /> /!1/I.) 5Y7o? T�N; R f(circle ore <br /> _Eor <br /> II Type of Building(check all that apply) Lot# <br /> �' Subdivision Name <br /> )-1 or 2 Family Dwelling-Number of Bedrooms <br /> s <br /> Bock# �- <br /> ❑Public(Commercial-Describe Use ❑ City of <br /> CSM Number ❑ Village of <br /> ❑State Owned-Describe Use <br /> 'own of <br /> III.Type of Permit: (Check only one box on line A- Complete line B if applicable) <br /> A ew System ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑Outer Modification to Existing System(explain) <br /> / List Previous Permit Number and Date Issued <br /> B. [I permit Renewal ❑Permit Revision ❑ Change of Plumber ❑Permit Transfer to New <br /> Before Expiration Owner <br /> IV.T e of POWTS System om nentTevice Check all that apply) <br /> Non-Pressurized In-Ground [I Pressurized hi-Ground El At-GladeEl Mound>24 un.of suitable soil ❑Mo�md<24 ins of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(e)plam) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(st) Disposal Area proposed kSys7ation <br /> VL Tank Info Capacity in Total #of Mmrufactia er Gallons Gallons Units New Talcs Erdsbn8 Tame <br /> a r^r.� <br /> septic ati. T'k- <br /> D D OI�D N es v <br /> Dosing Chamber <br /> VIL Responsibility Statement-f,the undersigned,assume responsibility for installs'on of the PowTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Si atu _771MP/1vSRS Number Business Phone Number <br /> WADE RUFSHOLM c 227691 715-349-7286 <br /> Phunber's Address(Street,City,State,Zip Code) <br /> h/ <br /> PO BOX 514,SIREN,WI 54872 <br /> VIII.Coun /De artment Use Onl <br /> Permit Fee Date Issued Issuing Agent Signature �1 5(Approved ❑Disapproved $�� L{. '7 <br /> ❑Owner Given Reason for Denial a 1 1 <br /> T1f.Conditions of Approvat/Reasoos for Disapproval <br /> )or—dc, 4,0 t �- <br /> Attach to complete plans for tic system and submit to the Coaaty only oo paper not less than 8>R z ff inches in size <br />