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;,rsu`.::,... County <br /> Safety and Buildings Division �j 6///-'/l/ <br /> `.;`` 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> ' S, � 1741 P.O. Box 7162 <br /> , Madison,WI 53707-7162 <br /> =' G5-1--- 14-314 <br /> State Transaction Number <br /> Sa•,itary permit Application pwTS - osi�ovoo y,mR <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 flan mailing address) <br /> the Department of Safety and Professional Services. Personal information you provide may be used for secondary ` /s <br /> % C�y s-� 0/0 <br /> purposes in accordance with the Privacy Law,s.15.04(I)(m),Stats. J " <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel#0 7 0;.3 ei,2 3 7/S' 7 - <br /> Gre.c Ve c,A)t(e /5- 7/3 0 70 o° 42461'4 <br /> Property ner's�lcIailing Address r�1/� Property Location <br /> 53 V7 c e.c//�'rw o et G.�F Govt.Lot <br /> City,(State II Zip Code Phone Number ie /, 'A, Section e2 7 <br /> (/ill, 06e 1` L�kc_ /)//v. 55//O L/`7/ .3. 3 / 7n esJ (circle one <br /> �Q T 3 7 N; R /2 E or <br /> � <br /> U.Type of Building(check all that apply) Lot# <br /> 1 or 2 Family Dwelling-Number of Bedrooms c.9 a Subdivision Name j <br /> Block# _5'4/4.0/p "°//i-//o/t <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> CSM Number ❑Village of <br /> ❑State Owned-Describe Use0-Town of fill-d e- L <br /> lit.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. New System Replacement System 0 Treatment/Holding Tank Replacement Only Other Modification to ExistingSystem(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 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) 0 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 /> 30 a , s' 3o d :70 C) 99, 7 <br /> VII.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units L o ,b, 0 <br /> New Tanks Existing Tanks et e. o d • ,g i <br /> a. U in . rn u, t.7 a. <br /> Septic or Holdifte-T-ank y Yo Cyd 1 <br /> Dosing Chamber 560 CC) ✓-) /e"J <br /> VII.Responsibility Statement- I,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 ,!�/i B't'/� 227691 715-349-7286 <br /> tea{ u <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 <br /> VIII.County/Department Use Only • <br /> � Permit Fee Date Issued Issuing Agent tgna <br /> Sit;(Approved 0 Disapproved I 4...e.....6.„....../4...e.....6.„.....4...e.....6.„....../ <br /> 0 Owner Given Reason for Denial 37 5 -1---' /.S/7 CE <br /> IX.Conditions of Approval/Reasons for DisapprovalAppRovED R I V <br /> MAY 14 2019 li <br /> ++DD <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11'pptfiM'' l3RII r COUNTY <br /> ZONING <br /> SBD-6398(R0313) <br />