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�pTBidIF,yT� County <br /> Safety and Buildings Division )64l1"na e, <br /> 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> S P !"� P.O. Box 7162 <br /> ` S ' Madison,WI 53707-7162 <br /> Sanitary Permit Application State, Number <br /> In accordance with SPS 38311(2),Wis.Adm.Code,submission of this fonn 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 inliumation you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s. 15. I m),Stats. Y/O/ G, <br /> L Application Information—Please Print All Information <br /> Property Owners Name Parcel# p 7 p ;;K G oZ <br /> =f e.�,tJ S CrJ,4. 0 000 p <br /> Property Owner's Mailing Address Property Location <br /> 410 <br /> r ll <br /> T A v /�ttJ G /'G e— Govt.Lot <br /> City,State <br /> Zip Code Phone Number /. V,, Section O <br /> �n('/�7 e A t0 O/o C,)_�, !T 7 N; R 6circle oo� <br /> II.Type of Building(check all that apply) Lot# <br /> Xkor 2 Family Dwelling—Number of Bedrooms 73 Z71 Subdivision Name <br /> Block# <br /> ❑PublietCommercial—Describe Use ❑City of <br /> CSMNumber ❑Village of <br /> ❑State Owned—Describe Use C e w <br /> V � P''fown of <br /> III.Type of Permit: (Check only one box 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 /> List Previous Permit Number and Date Issued <br /> B. [IPermit Renewal ❑Permit Revision [I change of Plumber ElPermit Transfer to New <br /> Before Expiration Owner <br /> IV.Type of POWTS S stem/Com onent/Device: Check all that apply) <br /> Ton-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(gpdsf) Dispersal Area Required(sl) Dispersal Ana Proposed(sf) System Elevation <br /> _7 <br /> VI.Tank Info ��ilY Total #of Manufacturer o o <br /> Gallons Gallons Units U U <br /> New Tanks Existing Tanks <br /> Septic ordlaldiog-Tank ea U o r <br /> Dosing Cbamber <br /> VIL Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber s Signaturen MP/I�RS 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 /> VIIL Coon /De artment Use Only <br /> �pprol <br /> ed ❑Disapproved Permit Fee Date Issued Issuing Agent Signature <br /> ❑Owner Given Reason for Denial $ -97S' O /0"Z b to <br /> IX.Conditions of Approval/Reasous for Disapproval p <br /> AC Pow�f %o Reel ACL f,�f 6Acif't— /l/ofifeawiv oN /'�e� `aH, ..� .r. G 1� E <br /> OCT 2 6 2016 In <br /> Attacb to eomplete plans for the system and submit to the County only on paper no"gimn in size <br />