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County <br /> Safety and Buildings Division 64 r/V <br /> 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> P.O.Box7162 <br /> Madison,WI 53707-7162 <br /> Sanitary Permit application State Transaction Number <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 Services. Personal information you provide may be used for secondary 6 j <br /> Rurposes in accordance with the PrivacyLaw,s.15.04 1 m,Stats. <br /> I. Application Information—Please Print All Information <br /> Property Owner's Name Parcel# 07 03;2 / /6 :3 j J <br /> PA- / Sil-I /5-, 5: e 2�oA t3 z2L 3 <br /> Property Owner's Mailing Address Property Location <br /> e rPA c e— f Govt.Lot <br /> I City,State n �) Zip Code Phone Number!� j y, %,, Section�A- � /I/ 5G 00 / .5 0 7 3s/ ��b (circle one <br /> II.Type of Building(check all that apply) Lot# T�N; ot� <br /> or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> i !!! Block# <br /> ❑Public/Commercial-Describe Use / �- <br /> ❑ City of <br /> ❑State Owned-Describe Use <br /> —�� CSM Number El Village of <br /> gown of —` ZC,/ <br /> III.'Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A, i ❑New System %{e stem tacement S y p y ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> ❑ 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 apply) <br /> 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.Dispersal/Treat ent Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> �s g(S 0 Fly, / <br /> VI.'Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o <br /> New Tanks Existing Tanks - o y p R <br /> a. U va y ra w C7 fi, <br /> Septic or Ff41irrC-Tank a vs e) /AQd <br /> Dosing Chamber /G' <br /> VII.Responsibility Statement- 11,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 1 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 <br /> VIII.Cowin /IDe artment Use Only <br /> proved ❑Disapproved $ermit Fee Date Issued Issuing Agent Signature <br /> ❑Owner Given Reason for Denial <br /> I%.Conditions of Approval/Reasons for Disapprova➢ <br /> E � <br /> 1 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 1 ch si <br /> Gt;r <br /> `7 UU <br /> SBD-6398(R03I3) <br /> urn County <br /> n / Land ServiceCe s Department <br /> 7y l <br />