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�ypNT,\/Yt County <br /> Safety and Buildings Division ,Bu r AJ e- <br /> j D$ �K! 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> y� P s P.O. Box 7162 <br /> Madison,WI 53707-7162 <br /> S �1cG <br /> Z- <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 38321(2),Wis.Adm.Code,submission of this fort 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. 1 m,Stats. O (� <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# 0 .7 e9,2 0 v2 VC) %6 0 7 <br /> eFrG PoJC9 / C1760 000 <br /> Property Owner's Mailing AddressProperty Location <br /> $ 19 Gro-S Po/",)+ <br /> I!z S Govt.Lot <br /> City,State Zip Code Phone Number y� <br /> / /., Section <br /> L C ffff e- G rL3 / e MJ a S^Q (� e-1' N; R <br /> (circle one)_ <br /> U.Type o Building(check all that apply) �^ Lot# (circle one)_ <br /> � r 2 Family Dwelling-Number of Bedrooms 7 Subdivision Name <br /> Block# R /ft)(2 V^ Q �� <br /> ❑Public/Commercial-Describe Use ❑ City of <br /> ❑State Owned-Describe Use <br /> CSM Number ❑ Village of <br /> 12�Y'own of (::9 <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A, ❑New System ePlacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> ) <br /> B. ❑Permit Renewal ❑ Permit Revision El Change of Plumber ❑Permit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Owner 4S-..153 g_lit- ,O <br /> IV.Type of POWTS System/Component/Device: Check all that appI <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 /> Desi3 Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elation <br /> V1.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o v <br /> New Tanks Existing Tanks w <br /> 0 <br /> U %n y y i,.,0 a <br /> Septic or HoliNkpifunk loo6 <br /> Dosing Chamber /_ �U /SO <br /> Fr— <br /> VIL 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 Wc�i+'r� 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 <br /> VIII.County/Department Use Only <br /> Approved ❑ Disapproved Permit Fee Date Issued issuing Agent Signature <br /> $ 7Z . <br /> 11 Owner Given Reason for Denial 4(-3 b�i,( <br /> IX.Conditions of Approval/Reasons for Disapproval D <br /> n <br /> APR 2 8 2014 <br /> Attach to complete plan for the system and submit to the County only on paper not less than 8 19UR ate=COUNTY <br /> ZONING <br />