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`�Y.aar,,; County <br /> Safety and Buildings Division ,�y^,u.S_ <br /> S ".. 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> P S Madison,WI 53707-7162 <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 OZ f l?3,7 <br /> purposes in accordance with the Privacy Law,s. 15.04 1 m,Stats. An <br /> I. Application Information-Please Print All Information ee,r 4S G <br /> Pro rty Owner's N e Parcel#Q 7 p/,2 0 <br /> obPar TT �o/'/J 15 ia5/ 06,8000 15? <br /> Property Owner's Mailing Address Property Location <br /> a l�3 5-- .-7-vc-rso-J �-v� �J. <br /> Govt.Lot <br /> City,State I Zip Code Phone Number <br /> /e, /., Section L3_ <br /> Lake. circle one) <br /> II.Type of Building(check all that apply) Lot# T�N; R E or W <br /> k1 or 2 Family Dwelling-Number of Bedrooms 6 O Subdivision Name <br /> _ Block# A-go r Lo 44 t, ,, t/, <br /> ❑Public/Commercial-Describe Use <br /> ❑City of � <br /> ❑State Owned-Describe Use CSM Number ❑ Village of <br /> P'Town of .T14 G/CS O/fJ <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' ❑New System .Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> p <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑ List Previous Permit Number and Date Issuedd <br /> Permit Transfer to New !�����7 L <br /> Before Expiration Owner U <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/Treat ent Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> ell o1 <br /> . 7 6 412 9 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units .n - o ,�, Q <br /> New Tanks Existing Tanks c Y ro <br /> cC U in ti A is. U G. <br /> Septic or HeWin*Jank 0400 <br /> a D —� �D�O <br /> f.2 in <br /> Dosing Chamber 400 <br /> — QOCA." F — X� <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 /_ 1 / 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 /> Permit Fee Date Issued Is ui ent S' <br /> Approved ❑ Disapproved $� � / <br /> ❑ Owner Given Reason for Denial I <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> SE P Q 6 2023 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 11 i c i , e <br /> ana ervlces Department <br /> SBD-6398(R. 11/11) <br />