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S. <br /> osranrsigy\ County <br /> e I � Safety and Buildings Division BURNETT <br /> �p S 201 W.Washington Ave., P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> PS. Madison,WI 53707-7162 Ts� <br /> Sanitary Permit Application State Transaction Number 0<3 <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form 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 Servies. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s. 15.04 1 m,Stats. <br /> I. A �4 3 57 <br /> Application Information-Please Print All Information J �Nv ,(k <br /> Property Owng's Name / r Parcel# 07-O S -0 -Jr <br /> / -o2.37 <br /> Z, 0 /S LV / / n✓�+ (00._#7 <br /> �a 7 0.5= 00 //- O /Vo©c) <br /> Property Owner's Mailing Address /t /9(/� /�A (/��y,) Property Location <br /> 35/ G � 'V ` e�� In r�� /t V Govt.Lot <br /> City,state Zip Code Phone Number , , <br /> C/ Section <br /> 5197-?' 3 (circle one <br /> II.Type of Building(check all that apply) Lot k T O N; ot�Y <br /> or 2 Family Dwelling-Number of Bedrooms / Subdivision Name <br /> / Block 8 <br /> ❑Publie/Commercial-Describe Use T� <br /> El City of <br /> El State Owned-Describe Use CSM Number ❑ Village of <br /> '/a '7 / 0-Town of L-44q -- -e� <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) 0111�}-oZ �r <br /> A. ❑New System a lacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> ) <br /> B. C1 Permit Renewal 13 Permit Revision 11 Change of Plumber <br /> ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: Check all that apply) <br /> D(Non-Pressurized In-Ground ❑Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in,of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dis ersaVrreatment Area Information: <br /> Design Flow(gpd) Design Soil lication Rate(gpdsf) Dispersal Area Required(s� Dispersal Area Proposed is t) System Elevation <br /> 3 dv , J° y129, �`- <br /> VI.Tank Info Capacity in Total 4 of Manufacturer <br /> Gallons Gallons Units 1, v <br /> New Tanks Existing Tanks y <br /> 6 V ti y w t7 P, <br /> Septic in 15eidingTIM /000 ._ Q(A <br /> Dosing Chnmber65-0 sb <br /> VII.Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> WADE RUFSHOLM rr- / � 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) (/r/ <br /> P.O.BOX 514,SIREN WI 54872 <br /> VIII.Court /De artment Use Only <br /> Approved ❑Disapproved Permit Fee Date Issued Issuin t Signature <br /> ❑ Owner Given Reason for Denial <br /> $ S 7 l2 <br /> IX.Conditions of Approval/Reasons for Disapproval g U T Lra U <br /> NOV 7 2012 <br /> Attachto cnmolete olans for the system and submit to the Coumv only on weer not less than 8 In 111 i <br /> ZONING <br />