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, X County <br /> "X Safety and Buildings Division pyr A) <br /> n 1(3 1:0$ 201 W_Washington Ave., P.O. Boz 7162 Sanitary Permit Number(to be filled in by Co.) <br /> P Madison,toll 53707-7162 <br /> Sanitary Permit Application Slate Tr action No, <br /> In accordenee with S13S38321(2),Wis.Aden Code,submission of this fort to me appropriate governmental unit F[yfC <br /> is required priorto obtaining a sanitary permit_ Note:Application to.,forstate-owned POWTS are submitted to Project Address QfdiBbrent than mailing address) <br /> the Department of Safety and Professional Servles. Personal information you provide maybe usN for secondary <br /> u res in accordance with the Privacy Law,s. 15.04 1 m,State. G Sys C C G leci <br /> I. Application Information—Please Print All Information <br /> property Owner's Nnme // Prieel q D 7'0 ;2 0-:,Z-4/0-/6-0 <br /> / <br /> Pmpenyfhvner's Mailing Address Properly LoeationP / <br /> w > ,Ion A) &-' Gac_Lot� <br /> CitgBtate Zip Code Phone Number it 9s, Serous <br /> O N lc a S' (circle one <br /> H.Type of Building all thlat apply) p Lot q 'I' �N, R�Eor� <br /> / i ort Family Dwelling—Numberofficdrooms 3 Subdivision Name <br /> Bloc N � <br /> ❑Publie/Commercial—Describe Use ❑City of <br /> ❑Stam Owned—Describe Use <br /> •l CSM Number ❑ Village of <br /> Ofownol �Q� f}/✓(" <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) po — <br /> A' ❑New System Y-Rephacmem System ❑ Treatment/l boding Tank Replacement Only ❑Other Mushiest..to Existing System(exphin) <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑Permit Transfer to New I's,Previous Permit Number and Dam Issued <br /> Before Expiration Ownv <br /> IV.Type of POWTSSystem/Component/Device; <br /> Check all tholes I <br /> Melon-Prsss'urbcd ba-Ground ❑ Pressurized lo-Ground 11 At-Grade ❑Mound>24 in ofsuitable soil ❑Mound 124 inufsoimble soil <br /> ❑ Holding Tank ❑Other Dispersal Componun(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> fiesign Plow(gpd) Design Soil Applieedon Rete(gpdsD Dispersal Arca Required(so in Elevation <br /> SU 61,9 <br /> VL Tank Info Capacity in 'Pch" <br /> qof .Manufacomer <br /> Gallons Gallons Units n <br /> Nis, Int" list gTvtks Ss jj <br /> s�rearrdk lel v0 Ooo �fyl � <br /> ooaing Chamaat <br /> VII.Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWI'S shown on the attached plans. <br /> Plumber's Name(Print) Phrome,s Signor. MP/MFRS Number BsessPhone Number <br /> WADE RUFSHOLM iJ z� 22)691 7l'5149-7286 <br /> G <br /> PO BOX <br /> 4,SIR N,eet,WI City,State,Zip Code) <br /> PO ROX 514,SIREN,WI 54872 <br /> VI .Count /De artin m Use Only <br /> Approved ❑ Disapproved Permgqit Gee l!qq�� Dam Issued Issuing Signazur- <br /> ❑owacr Given Reason for Denial S Vo25'7 r/ 1/ T De, ZC6 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach to complete Plans on,the...emitted enema ru be Countyrod,an leaner not less than 8 in,11 inches in a6e <br />