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Safety and Buildings Division <br /> 4 �I <br /> $ 1400 E Washington Ave Sanitary Permit Number(to be Stied in by Co.) <br /> S <br /> t t F P.O. Box 7162 < 2 <br /> E, Madison,WI 53707-7162 J�-7J-7•^� <br /> Sanitary Permit Application State TramacoonNumber <br /> In accordance with SPS 38321(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 diffy;ent than mailing address) <br /> the Department of Safety and Professional Services. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. 6�� <br /> L Application Information-Please Print All Information <br /> Property Owner' Name Parcel# O O 3>r e1 <br /> GJ�47/4c, L, (, 3 ov moa <br /> Property Owner'sMailing Address Property Location <br /> S G <br /> A Oj� a�r ��v a Govt Lot <br /> City,State Zip Code Phone Number �, O?!� <br /> // /Q d- _ /<,S %, Section <br /> web$/7` 7 y893 / (circle one <br /> II.Type of Building(check all that apply) Lot# T_�N, R& E o0 <br /> M1 2 Family Dwelling-Number of Bedrooms �- Subdivision Name_ <br /> .� Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> 2J'Town of �G�trd <br /> III.Type of Permit: (Check only one boa on line A. Complete line B if applicable) <br /> A- ;New System ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B- ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: Check all that a l <br /> ?4lon-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑Mound>24 in_of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(sf) DispTal Area Proposed(sf) System Elevation <br /> ' <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o$ v <br /> New Tanks Ezisftg Tanks u G v = y .2 r <br /> a U in y rn i:.C7 a. <br /> Septic or Heiiimg.Lank 75-6 <br /> Dosing Chamber <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MPIWRS Number Business Phone Number <br /> WADE RUFSHOLM /,/ 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 <br /> VW.CountyMepartment Use Only <br /> (Approved ❑Disapproved Permit Fee Dilate Issued Issuing Agent Sign <br /> El Owner Given Reason for Denial $ 3 7S. 00 <br /> 1X_condiaons D E C E I tli^_ (� <br /> VE <br /> AUG 0 3 2016 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 lax 11 mehes in mbURNE <br /> CS TT COUNTY <br /> --- ---- ----- ZONING <br />