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County <br /> Safety <br /> �fi�; Safety and Buildings Division al j g <br /> 10 1400 E Washington Ave Sanitary Permit(Number(to be fined in by Co.) <br /> q4 <br /> P_O.Box 7162 J� (o t <br /> Madison,WI 53707-7162 I _ <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 38321(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 stat"wned POWTS are submitted to Project Address(if differentthan mg rens) <br /> the Department of Safety and Professional Services. Personal im brotation you provide may be used for secondary / v/�7 0�ktL)�t� Gt7� <br /> purpuses in accordance with the law,s.15A4(1 m,Stats. / / '` <br /> L Application Information—Please Print All Information Parcel# O 7 n! -7 <br /> Properly Owner's Name <br /> �/J e r s 52� a /(9'9C> <br /> Property ces Mailing Address Property Location <br /> /J y` �� Govt Lot <br /> city,state =7� 2 <br /> Phone Number yy /y Section-.Z <br /> —7 <br /> \ lle one) <br /> ff— <br /> T '4/ N, R�Eor <br /> IL Type of Building(check all that apply) Lot# <br /> �J // Subdivision Name <br /> Kior2Family Dwelling-Number ofBedrooms y� // J <br /> � Block# �a, <br /> ❑Publio/Com mercial-Describe Use ❑City of <br /> �— CSMNumber ❑Village of <br /> ❑State Owned-DescnbeUse ATownof <br /> 1II.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A- KNew System ❑Replacement System ❑Treatment0olding Tank Replace rent Only ❑Met Modification to Etdst mg System(explain) <br /> B. ❑ Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/ <br /> Component/Device: TClleck all that apply) <br /> Non Pressurized im-Grotmd ❑Pressurized lo-Cimund ❑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/Tr -ent Area Information: <br /> cation Rare(gpdst) Dispersal Area Required(s� Dispersal Area Proposed(sf) System Elevation <br /> Design Flow(P-Pd) Design Seri App'h <br /> Z) �� e) Gov 13 <br /> VL Tank Info Capacity in Total #of Manufacturer S c 0 <br /> Gallons Gallons Units a o 0 <br /> New Tanks Existing Tanks k E d .2— <br /> m <br /> Dosing Chamber <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for installation of the POWTS shown OR the attached plains. <br /> Plumber's Name(Print) Plumber's Signature TW/=NWW—RSNumb­cr Business Phone Nmmmber <br /> WADE RUFSHOLM 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 <br /> yM County/Department Use Onl <br /> Permit Fee O D(afte Is <br /> s <br /> ued Issuing Agent Si <br /> Approved ❑Disapproved $ 7� % <br /> ❑Owner Given Reason for Denial <br /> M Conditions of ApprovAMeavoas for Disapproval <br /> Attach to complete plant for the system and submit to the County only 00 paper not less tbam a M x Dx ind kes iu sae <br />