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County�J <br /> Safety and Buildings Division g, A) <br /> 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> P S Madison,WI 53707-7162 �, f �.��17 <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 '1 <br /> purposes in accordance with the Privacy Law,s. 15.04 1 m,Stats. <br /> I. Application Information—Please Print All Information <br /> Property Owner's Name Parcel# C J 0 © ? 7 5— <br /> .S c-v74 C" —b AA/'f C, <br /> Pro/perry Owner's Mailing Address ) Property Location C, <br /> b ; q1-n ✓� G,4 e, Govt.Lot 6 <br /> City,State Zip Code Phone Number �/, '/,, /<, Section Z <br /> /7 7 �/ (circle one <br /> II.Type of Building(check all that apply) Lot# T 44 N; R A L E o <br /> J <br /> D`i or 2 Family Dwelling—Number of Bedrooms - 1 Subdivision Name <br /> �— Block# <br /> ❑Public/Commercial—Describe Use <br /> ❑ City of <br /> ❑State Owned—Describe Use CSM Number El Village of / <br /> VLA D A Town of �i�AC <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑New System y ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> y Replacement System <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: Check all that appi <br /> L/I 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 /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units a o ° o <br /> �N U U <br /> New Tanks Existing Tanks <br /> t U H w 0 a. <br /> Septic or k an c / Q 0 <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 MP/MPRS Number Business Phone Number <br /> WADE RUFSHOLM 1 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) (/t/ <br /> PO BOX 514,SIREN,WI 54872 <br /> VIII.County/Department Use Only <br /> Approved El Disapproved $ermit Fee Date IsQsued Issui g gent S' to <br /> ❑ Owner Given Reason for Denial <br /> IX.Conditions of Approval/Reasons for Disapproval D <br /> flow I Q r (�t ,4v q4d s4a-k rerr,U e��s OCT 0 9 2023 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 1 inches in si$urnett ounty <br /> Land Services Department <br /> SBD-6398(R. 11/11) j y155 (V v l JJ -# u i2 <br />