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$4 jq6 TAI}1T�,4 County <br /> Safety and Buildings Division ��!/itJ G' <br /> J ( fJ$ 1400 E Washington Ave <br /> F P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> _ S �1 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 Services. Personal information you provide maybe used for secondary <br /> purposes in accordance with the Privacy Law,s. 15.04(1)m,Slats. <br /> 1. Application Information—Please Print All Information <br /> Property Owner's Name r / Parcel#B 7 0-0-C <br /> Property Owner's Mailing Address Property LocatioWc <br /> o7ty yye/ i % <br /> Govt.Lot <br /> City,State g Zip Code �y Phone Number 56'©Y., S c� Y., Section l d <br /> T �O N; R _(circle cme <br /> H.Type of Building(check all that apply) Lot# <br /> or 2 Family Dwelling—Number of Bedrooms �� Subdivision Name <br /> ,I i Block# <br /> ❑Publie/Commercial—DescribeUpe �— <br /> ❑ City of <br /> ❑State Owned—Describe Use �— CSM Number ❑ village of_ <br /> 1c Town of e- <br /> 111.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ew 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 /> 14 Non-Pressurized In-Ground ❑Pressurized In-Ground ❑ At-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑ Holding Tank ❑tether Dispersal Component(explain) _ ❑Pretreatment Device(explain) <br /> V.Dispersal/Treati6ent Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sq Dispersal Area Proposed(sf) System Elevation <br /> 9�,s <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o$ <br /> New Tanks Existing Tanks <br /> Septic or FlOWiugTADk 0 Q <br /> Dosing ChamberLd <br /> VII.Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MI'/M IRS Number Business Phone Number <br /> WADE RUFS14OLM /. )�cL�— z Z 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 /> Permit Fee Date Issued Issuing Agent Sig tur <br /> Approved 11Disapproved S _ Od <br /> ❑ Owner Given Reason for Denial J( $ �� r /Z L <br /> IX,Conditions of Approval/Reasons for Disapproval , S %.rrSf�Cr�i dsf �lP� �G .Se7'YdG, S <br /> 41m W f ZC .5 oaOW v PLo,� PLa A"Ifew CJ!L <br /> D _ C <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 in x I nch in in' 0 C 2016 <br /> BUAARNETr COUNTY <br /> ZONING <br />