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rr 1 County <br /> Safety and Buildings Division j q/.,��,i g <br /> . g s , :'-'1 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.)_ <br /> '. 130 P.O.Box7162 5a7J-1q-cob tO/`gf15-- <br /> Madison,WI 53707-7162'- \ /1�9 p J <br /> / e,. . -19 - 7k <br /> Sanitary Permit Application State Transaction Number . <br /> in accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate govermnental 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 Infformation-Please Print All Information / ` / 0 rj.�.'///,,4 LJ k <br /> Property Owner's Name Parcel# C; 7 G O /ram .1 341ZY7 / <br /> G- <br /> ei" <br /> Property Ow/n atling ddress / ! ` Property Location /')r.,/ <br /> 3 J t f C.A l`/"'j/ c e:.. /1 i u/ /r kc Govt.Lot_ 5-�"f, <br /> City,State - Zip Code Phone Number y, %,, Section ,„_;,..,/ <br /> 1 ,-. <br /> ) <br /> s.')/11f()A")"(_".- in 1 rk' :577:5 a L (circle one <br /> IL Type df'Building(check all that apply) Lot# -� T --- ! ' N; R /7 E o 1> ' <br /> ❑ 1 or 2 Family Dwelling-Number of Bedrooms .___ Subdivision Name <br /> Block# <br /> Public/Commercial-Describe Use ❑City of <br /> ❑State Owned-Describe Use CSM Number 0 Village of <br /> Mown of ,d n A%b'e 5 <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. lew SystemReplacementSystem8 ReplacementOnlyExisting System(explain) <br /> // ❑ 0 TreatmenUHoldin Tank 0Other Modification to <br /> B. ❑ Permit Renewal ❑Permit Revision ❑ Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration I Owner <br /> HIV..Type of POWTS System/Component/Device: (Check all that apply) <br /> JdCNon-Pressurized In-Ground 0 Pressurized In-Ground 0 At-Grade 0 Mound>24 in.of suitable soil 0 Mound<24 in.of suitable soil <br /> ❑ Holding Tank 0 Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> V.Dispersal/I'reatment 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 I Manufacturer I I I I <br /> Gallons Gallons Units ) o ,d, o <br /> New Tanks Existing Tanks i o $ I 1 3, m <br /> A.' U i r . rn ii C7 a. <br /> Septic or#1d1C1 ank - / <br /> 1, t> - - <br /> AZ 5 G) / .e.'e- <br /> Dosing Chamber <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 ,✓2 MP/MPRS Number Business Phone Number <br /> WADE RUFSHOLM 66/` ! 'f, 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) J �r , <br /> PO BOX 514,SIREN,WI 54872 <br /> i VIII.County/Department Use Only <br /> Approved ❑ Disapproved Permit Fee Date Issued Issuing Age trSignature <br /> ❑Owner Given Reason for Denial 3 /J 9 if ( (/' fit ��.,}}� j'�],t� `/ <br /> IX.Condition f s r Disapproval ... ...(1-1"�"—`b 2 <br /> a rE, 0 ELVt <br /> Attach to complete plans for a system and submit to aunty only on paper not less than 8 1/2 a in sin/U L 5 2`1g t —ii ' <br /> • <br /> AUfreeiLe A_ <br /> SBD-6398(R0313) <br /> Burnett Cutantn y � <br /> ' ?— --/f Land aarvic&ls DePartment <br />