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county <br /> Safety and Buildings Division <br /> !q/t 1400 E Washington Ave Sanitary Permit Number(to be filed in by Co.) <br /> � �'' P.O.Box 7162 t- <br /> 1�.� �S /�,> >�J4`f�'7 <br /> oA ��f� Madison,WI 53707-7162 {�/•�� <br /> r AV -5 / — <br /> Sanitary Permit Application Sm Transaction Number <br /> in accordance with SPS 38321(4 Wis.Adm.Code,submission of this:Corm to the aPP"nate 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 Proffcssional Services. Personal information you provide may be used for secondary <br /> Purposes in accordance with the Privacy Law,s.15_ l m Stars. <br /> L Application Information—Please Print All Information C_ G- <br /> Property Owner's Name <br /> Property Owners Mailmg Address Q Property Location <br /> o9'S 10 C- /I r� Govt.Lot <br /> city,state <br /> , f g Zip Codecp LPhone Number <br /> o / y, yg Section <br /> IN [/(}_14 R /!{(cUclEore&) <br /> EL Type of Building(check all that apply) Lot# <br /> Sision Name <br /> A JI or2 Family Dwelling—Number of Bedrooms Block# i--�"11� <br /> ❑Publir/Commercial—Describe Use ❑ City of —'y <br /> ❑State Owned—Describe Use CSMNumber ❑Village of �— <br /> (./ 7 g '.Town of L d <br /> r / <br /> III.Type of Permit: (Check only one box on line A- Complete line B if applicable) <br /> A- �New System ❑Replacement System ❑Trealment/Holding Tank Replacement Only ❑Other Modification to Existing system(explain) <br /> B. ❑Permit Rzoewal ❑Permit Revision ElCharge of Plumber ❑Permit Transfer to New Lis[Previours Permit Number and Date Issued <br /> Before Expiration I Owner <br /> IV.T e of PO W r$S m/Com or entWevice: Check all that ap2W <br /> Non-Pressunzed 1n-Ground ❑Pressurized le-(Hound ❑At-Grade ❑Mound>24 m.of suitable soil ❑mound<7,4 in.of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(Main) <br /> V.Dis ersalfri-eatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rdu(Wp lsf) Dispersal Area Required(A) Disposal Area Proposed(st) System Elevation <br /> 1 AV17 6 � Asa 9� <br /> VI.Tank Info Capacity in Total #of Mamdacnner <br /> Gallons Gallons Units v <br /> m a U 6 2 <br /> `m <br /> New2anks Erdstnag Tanks w o B 2 p; .o� <br /> wr7 A. <br /> septic or mg an hod �.?? c�/'r;c1 :-5 C- d 7L• <br /> Dcsiag Chamber <br /> VII.Responsibility Statement- L the undersigned,assume responsibility for installation of the POVM shown on the attached plans. <br /> Pltmnber's Name(Print) Plumber S Signature MPMIPRS Number Business Phone Number <br /> WADE RUFSFIO]M (�/_�/UGC/PJ 227691 715-349-7286 <br /> Pl mbees Address(Street,City,State,Zip Code) <br /> PO BOX 514,SWEN,Wl 54872 <br /> VM CountyWepartment Use Only <br /> Approved ❑Disapproved Pennitt Fee 00 Date Issued lssuimg Si <br /> ❑ Owner Given Reason for Denial $ v`�• ���D <br /> M Conditions of A,pproval/J[teasous for]Disapproval <br /> Attach to complete plans for the ayslmu and submitto the County nay on paper not lea than 8 W x 11 iocbrs in sde <br />