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/$"Br— County <br /> rl \a` Safety and Buildings Division ,ld e� <br /> 1400 E Washington Ave sanitary Permit Number.(to be filled in by Co.) <br /> i3 P.O. Box 7162 _(� <br /> P S Madison,WI 53707-7162 r! 'I <br /> �rvnn` <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 38321(2),Wis.Adm.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 i Z-p �/L o7i-K� <br /> purposes to accordance with the Privacy Law,s.15.04(L m),Stats. `)/ 6 fL <br /> 1. Application Information—Please Print All Information <br /> Property 0er's Name —I1 Parcel# O '� / / <br /> rtlGt✓� C� ...3 C' C�60 `SC ©O <br /> Property Owner's Mwlmg Addres 1 Property Location P <br /> () /3�aCF w�t N Govt Lot <br /> City,State Zip Code Phone Number S� �,�li✓ yy Section <br /> (circle one <br /> II.Type of Building(check all that apply) Lot# <br /> �1 or 2 Family Dwelling-Number of Bedrooms 12 Subdivision Name <br /> Block# <br /> ❑PublidCommercial-Describe Use ❑ City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> V///GTown of <br /> III.Type of Permit: (Check only one boa on line A. Complete line B if applicable) <br /> A-A_ )(New System ❑ Replacement System ❑TreatmenV11olding 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 S stem/Com onent/Device: Check all that a <br /> XNon-Pressurized In-Ground ❑Pressurized hi-Ground ❑At-Grade ❑Mound>24 m_of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.DispersaVrreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rabe(gpdsf) Dispersal Area Required(st) Dispersal Area Proposed(d) System Elevation <br /> c' v / 7 y y <br /> V1.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o 02 y <br /> New Tanks Existing Tanks v o g MV 2 `2 <br /> inn <br /> ,�� II w C7 a. <br /> Septic or FloldmgT=k /Oo '—' D �j f Cr�5Cto <br /> Dosing Chamber <br /> VIL Responsibility Statement—1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumb s Signature MP/MPRS Number Business Phone Number <br /> WADE RUFSHOLM ! �/ 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) �i <br /> PO BOX 514,SIREN,WI 54872 <br /> VIII.County/Department Use Only <br /> Approved ❑Disapproved Permit Feer D Date Issued Issuing Agent Signature <br /> El Owner Given Reason for Denial $ �J O� / // <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8112 x 11 inches in sin <br />