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County <br /> 1 \ Safely and Buildings Division a r.N e- <br /> 1400 E Washington Ave Sanitary Perron Number(to be filled in by Co.) <br /> P.O. Box 7162 <br /> \ l Madison,WI 53707-7162 -5 I I-3�J�- 1I <br /> Sanitary Permit Application Slate l tans ion Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to me uppruprim a govcumcntul unit <br /> is required prior to obtaining a sanitary Perrin. Note:Application forms for state-owned POWIS aresubmitted to Roject AJJress(ifdifferent Rmn mailing address) <br /> the Department of Safety and Professional Services. Personal information you provide may be used for secondary /, o/� <br /> p.m..is..card...with the Privac Lim.s. 15.04 1 m,Stats. 3/ 8 Q/ N R(/ N G /✓ �' <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name - Pared 07 032 nr—, <br /> OSSOQ O OOC) <br /> Property Coach%Mailing Addressll Property Location <br /> 3742 5/9 �Je— S cU Govt],at—L-L-2 <br /> City,Stat. Lip Cade Phone Section <br /> Number SE r, e� /3 <br /> q �// �/., <br /> � <br /> / Oj6/ �-5-as 9- //6 Thr�/� N; <br /> Ido � <br /> II.Type of Building(check all th.t apply) of H It Ea W <br /> �4or 2 Family Dwelling-Number ofdedrooms <br /> ❑Public/Commercial-DescribeUse pieced <br /> ❑city af <br /> ❑State Owned-Describe Use `—� CSM Number,- ❑ Villageaf �-- <br /> 111.Type of Permit: (Che`c,� m <br /> k_only one box on line A. Complete line B if applicable) <br /> A. ❑New System p-tecpkxcment System ❑ IiemenVHolding Took Replacement Only ❑Other Modification to Existing System(explain) <br /> B. El Permit Renewal Permit Permit Revision ❑ Change of Plumber ❑Pemtit Transfer lm New List Previous Permit Number and Daze Issued <br /> Before Expiration Owner <br /> IV.Type ofPOWTSSstem/ComonenUDevice: Check alithatapply) <br /> orvPressurizcd In-Ground ❑ Pressurized In-Ground ❑At-0rude ❑ Muund>_24 in.cfsuitabie soil ❑ Mound 124 in9 ofsaitable soil <br /> 11 Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Doeice(explain) <br /> V.DisitcrtialrTretument Arca Information: <br /> Desi Flow(gpd) Design Soil Application It p lsf) Dispersal Area Required(s0 Dispersal Area Proposed(s0 System Elevation <br /> �O-b 17 1125, //SO 9S.3 <br /> VI.Tank Info Capacity in Total 4 of Manufacturer <br /> Gallons Gallons Units a cg <br /> Ncwl'ankx E.iniay Tan4a N - ,x 0 <br /> w iJ <br /> gestic or lloMhtgi'aak 7s'v SO C, /71 C_ <br /> Posing Chembrr <br /> VI I.Responsibility Statement- 1,the madera gned,assume responsibility for installation or the POwTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's SignatureMP/MPRS Number Business Phone Number <br /> WADE RUFSHOLM / f 227691 7I5-349-7286 <br /> Plumber's Address(Slr.[,City,Stale,Zip Code) <br /> PO BOX 514,SIREN,WI 54872' " <br /> VIIL count /De nrImen I Use Onl <br /> (�Appraised 11ved Disapproved P.Mlil Pec Date Issng suued L suiAgent Si, afore <br /> El Owner Given Reason for Denial /% <br /> IS.Conditions of ApprovaUReasons for Disapproval L) <br /> 4 L L-Ti L}fl l <br /> SEP — 2-2014 J <br /> CS-��I({ � nu.chmramNnm Mem rot the:mem ane mbmu t.me cnnnry Dolt an P.nrrn.ues mm egt�Rq�ynt.l�OUNTY <br /> ZONING <br />