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• <br /> County <br /> Safety and Buildings Division t 2 Lj f'A) e..,t1— <br /> '.=;' a 0 . ---.: 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> .-" 2,..,, ti I.-: <br /> Madison,WI 53707-7162 <br /> ,gflit•1—23 -/IQ <br /> 4,2-6 6W' <br /> 2.- <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 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 Servies. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s. 15.04(1Am),Stats. <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name/ Parcel# 0 7 c9 42 07 90 /.5"/ <br /> /1)aS 5 e I VAALtier we r-r-r j s7 ' a yA0,,, <br /> Property Owner's Mailing Address Property Location 4fr erki <br /> y <br /> ,72 F 7.5--/ 7-""%i-e..e. /2.2,/e, if di Govt.Lot <br /> City.State I Zip Code Phone Number <br /> v,,, <br /> 1/4, Section /5 <br /> 0 h-/t)4 w cy (.(2.F 15"-arge. //,5--20.5 3 ?.,.2. T N Rj6_ circle one <br /> Ye' ; Eolffik <br /> II.Type of Building(check all that apply) Lot# <br /> x <br /> A 1 or 2 Family Dwelling-Number of Bedrooms •= 3/-fr.3,Z Subdivision Name 7.--/.*c,4;74 <br /> Block# Add 14-"D V.,....--- <br /> 0 Public/Commercial-Describe Use <br /> ---- 0 City of <br /> —_-.. --- <br /> 0 State Owned-Describe Use CSM Number DI Village of <br /> ..-- Town of a-4C IC 5 o'T.-) <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. 0 New System ..Replacement System 0 Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> • <br /> B. ElPermit Renewal 0 Permit Revision 0 Change of Plumber DI Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> I 1 <br /> W.Type of POWTS System/Component/Device: (Check all that apply) <br /> KNon-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 /> El Holding Tank 0 Other Dispersal Component(explain) D Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) I Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 3 eo 1 r 7 i i 2s. ,6 5--0Y' <br /> VI.Tank Info Capacity in Total --#of Manufacturer <br /> lu, <br /> Gallons Gallons Units <br /> - <br /> New Tanks Existing Tanks '. . '' 15 g tl <br /> k) (5 .,7, v,. ,7, i::: 3 <br /> Septic or HeyirertrTank /674)e --- /4 / /Z.Jc,/- e. .5 a 1-- <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) Plumbe 's Signature MP/MPRS Number Business Phone Number <br /> WADE RUFSHOLM <br /> a.4--- 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 0 Disapproved <br /> Permit Fee Date Issued Issui g ent Sign/ re <br /> A <br /> li( 1 aV--'-'s . <br /> 1 0 Owner Given Reason for Denial $1-1>-5--- Iiid-0/13 - .. / <br /> I.X.Conditions of.Approval/Reasons for. Disapproval +s <br /> 7 _ <br /> .., 0 E V E prvi.e.t+- Il 50 (AA/6 ks-kfc 7.4, <br /> APR 1 8 2023 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/: x 11 imiii.si .: <br /> t3uthett County <br /> Land Services Department <br /> SBD-6398(R. 11/11) ojelut-toq t4-1Q:5°Q" <br />