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u, Counter <br /> Safety and Buildings Division ; <br /> 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> �=t P.O.Box 7162N a "Wb <br /> Madison,WI 53707-7162 <br /> 137 <br /> Sanitary pe .it 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 /�" <br /> purposes in accordance with the Privacy Law,s.15.04 1 m,Stats. /� <br /> I. Application Information-)Please)!Tint A➢➢Information �2 75�� A n e rm A(-k <br /> Property Owner's Name <br /> P Y ,w/ Parcel# �7p 5/� 0Z,3,�/�-3S/ <br /> 4 VcdD/U 45 -S ajj .0 D el OD l <br /> Property Owner's Mailing Address - L p Property Location.Ac- -3 7>Sj f <br /> 3 ^0 Govt.Lot /_ <br /> City,State Zip Code Phone Number <br /> c / /<, /., Section <br /> Reds'� 6 6, T (circle one <br /> 1 W, <br /> II.'Type of Bnil ��N; R E <br /> (check all apply) Lot#7 <br /> or 2 Family Dwelling-Number of Bedrooms G 04 r'I e pC fdL f Subdivision Name <br /> Block# _ <br /> ❑Public/Commercial-Describe Use — ❑ City of <br /> El State Owned-Describe Use <br /> CSM Number ❑Village of <br /> V Po-7[? V17p127 V-Townof <br /> III.Type of Permit: (Check only one box online A. Complete line B if applicable) <br /> A' V New System <br /> y ❑ Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> I !�! <br /> B• I ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> ICI.Type of POWTS System/Component/Device: (Check all that a ➢ <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/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> VI.'Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units a " i; 2 <br /> New Tanks Existing Tanks w p y o ^y a N N <br /> O a 72'g m <br /> a U in co w C7 a <br /> 1:i;--;;T0r Holding Tank <br /> Dosing Chamber <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 /�1 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 <br /> VIII.Cozen /IlDe artment Use Only <br /> Approved ❑Disapproved $ermit Fee Date Issued Issuing Agent Signature <br /> I ❑ Owner Given Reason for Denial I✓7S `S'S 2� J <br /> - ;��- <br /> IX.Conditions of Approval/Reasons for(Disapproval � I <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 es 1ZeMAY 0SBID-6398(R0313) BurnetLand Servic <br />