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County <br /> r4 ": Safety and Buildings Division f� <br /> S 201 W.Washington Ave., P.O. BOX 7162 Sanitary Permit Number(to be filled in by Co.) <br /> Madison,WI 53707-7162 <br /> P SI (03 83 I <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 fortes 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 3 p/,C— y�L7 .�/,� <br /> purposes in accordance with the PrivacyLaw,s. 15.04 1 m,Slats. c�U(I /7 <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel#lyur <br /> (fiC mg-a;06W <br /> Property Owner's Mailing Address Property Location <br /> Govt.Lot <br /> City,State Zip Code Phone Number y, �/4, Section lt✓ <br /> c circle one <br /> T `3f� N; R E o W <br /> H.Type of Building(check all that apply) 2 Lot# <br /> 1 or 2 Family Dwelling-Number of Bedrooms Subdivision/Name N <br /> Block# �`' � " Jl/ <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use <br /> '— CSM Number ❑ Village of <br /> ITown of ' <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. I New System ❑ Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <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 apply) <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 /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(so Dispersal Area Proposed(st) System Elevation <br /> �� J l &qg fc <br /> VI.Tank Info Capacity in Total #of Manufacturer 0 <br /> Gallons Gallons Units <br /> New Tanks Existing Tanks y k Uo p <br /> ii� ~n is C7 a <br /> Septic or HeldingT-ank <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 ' 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 <br /> VIII.County/De artment Use Only <br /> 4 Approved ❑ Disapproved Permit Fee [)c-2 Date Issued s i g 37� Agent Signature - <br /> ❑Owner Given Reason for Denial ' <br /> IX.Conditions of Appr val easons for Disapproval <br /> �►mee�- It 114�5 I <br /> AUG .fl 8 2M, � 1 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 11 int"ftrvlC�s j} <br /> SBD-6398(R. 11/I1) <br />