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County <br /> „ Safety and Buildings Division e, <br /> f p _ 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> P 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 Z 3 <br /> purposes in accordance with the PrivacyLaw,s. 15.04 1 m Stats. oZ 53,22 / Tax l� 3 <br /> I. Application Information-Please Print All Information NS i <br /> Prop rty Owner's Name Parcel#D-7 8 .7 39 / .2 <br /> e r 6,4 <br /> Property Owner's Mailing Address .f ' Property Location <br /> V`d K e, s/• A u) Govt.Lot <br /> Cay,Sttaaa e Zip Code Phone Number '/ y<, /., Section o2.� <br /> / �►„•)�l S /� J Ss O /2 y3 9 '+� .�� (circle on <br /> 'I.Type of Building(check all that apply) Lot# T —N; R�_E aW <br /> t �tj i or 2 Family Dwelling-Number of Bedrooms Z Subdivision Name r <br /> k _ <br /> Block# <br /> Ll Public/Commercial-Describe Use "— ❑ City of <br /> CSM Number ge of <br /> State Owned-Describe Use <br /> ❑ Villa <br /> 4 Town of <br /> Ill.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ( 1-4jew System ❑ Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> 3. ❑ Permit Renewal ❑ Permit Revision ElChange of Plumber ElPermit Transfer to New List Previous Permit Number and Date Issued <br /> E Before Expiration Owner <br /> ITT.T e of POWTS System/Component/Device: Check all that apply) <br /> i ❑Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> FJI 'oiding 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(sf) Dispersal Area Proposed(sf) System Elevation <br /> ' C,4 <br /> ¢✓I.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units a c v <br /> New Tanks Existing Tanks <br /> j U in ti cn ii C7 C'i. <br /> Saplisor Holding Tank >4__ <br /> Dosing Chamber <br /> i V1I.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> j Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> WADE RUFSHOLM / 227691 715-349-7286 <br /> I Plumber's Address(Street,City,State,Zip Code) <br /> j PO BOX 514,SIREN,WI 54872 <br /> mill.County/De artment Use Only <br /> Approved ❑ Disapproved Permit Fee Date Issued Issuing Agent Signature <br /> ' ❑Owner Given Reason for Denial $ C,(v <br /> IX.Conditions of ApprovaUReasons for Disapproval <br /> �u k bf d an UCLU k 024 <br /> 1.1 Attach to complete plans for the system and sub it to the County only on paper not less than 8 I/2 x 11 inches in size <br /> E3urnett County <br /> Land Services Department <br /> � �-�39g(R. 11/I I) , 315 tq&k #/V931 <br />