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County <br /> 2 <br /> , Safely and Buildings Division 6j rAi e— 14 <br /> 201 W.Washington Ave., P.O.Box 7162 Sanitary Por it Number B.he ntica m by Cud <br /> Madison,WI 53707-7162 S/a 6 883 <br /> yr <br /> State Transaction Numtxr <br /> Sanitary Permit Application � <br /> In accordance with SPS 383 21(2),Wis.Adm.Code,submission of Otis font to the appropriate g,ocmmemul it <br /> is required prior to obtaining a sanitary permit. Note:Application fomes for state-owned POWTS we submitted to Project Address(if,increm then meilingaddrrss) <br /> the Department of Safety and Professional Scivies. Personal information you provide may be used for secondary <br /> plimliones in weardance with me Privacy I.aw,s. 15.61 I m Stec. <br /> 1. Application Information-Please Print All Information <br /> Propeny Owner' Nanm Pmcd a 77 0 QQ 6 <br /> er re �o� 95-00/ a/Sono <br /> Propeny Owner's Mailing Address Property Location <br /> J o Govt.I.ot I <br /> City,State Lip Cute ['hone Number g,_'/., Section <br /> �,, syg3a �6— 5�ai6 ''//i le on <br /> pe oe <br /> T_ N; R�Ear� <br /> II.Tyfr ilding(check ell that apply) Lot N <br /> 7a,2 Family Dwelling-Number of Bedrooms SuMtlivincia Nmu <br /> Block e <br /> ❑Public,Commercial-Describe Use <br /> ❑City cf <br /> ❑State Owned-Describe Uu CSM Number ❑ Village of <br /> -va3 p �3 <br /> Ill.Type of Permit: (Check only one box online A. Complete line B if applicable) <br /> A. <br /> 01 New System A Replacement S)smm ❑ToarmuctUolding lank Replacement Only ❑Oth<r Molifcatinn m Existing Systcm(explain) <br /> B. 0 Permit Renewal 0 Permit Revision ❑Chrvtge of Plumber ❑Pertnir'fmnsfeno Ncw List Previous I'cnnit Number and Dale Pound <br /> Before Expiration Owmr <br /> IV.Type of POWrS S stem/Com anent/Device: Check all that apply) <br /> y4 Non-Pressurized In-Ground 0 Pressmired In-Ground ❑ AlGradc ❑Mound>24 in.ofsnlmble soil ❑Mound<24 inofsuitable soil <br /> 011a1ding Tank ❑Other Dispersal Component(aplain) O Pretreatment Device(explain) <br /> V.Dis ersalffreatm eat Area Information: <br /> Design Flow(pit) Design Sail Application Rate(gpdsQ Dispersal Arca Required(at) Dispersal Area Prapmcd(s0 Svstem Elevation <br /> o v 7 Ya7 <br /> VI.Tank Info Capacity m Iis[ p of Mmral'actu cr <br /> Gallons Gallons unity o 15 <br /> U = <br /> Ncw Tonka Pxiving Tun4a c y <br /> U 3 - a <br /> a` O e. <br /> Sepicm Holding Tank <br /> a"" =e _ 7971 7S6 / IaJcbtfv X <br /> VII.Responsibility Statement- 1,the undersigned,assume r<sponsibilitr for installation of the PORTS shown on the attached plans. <br /> ['lumbers Nmnc(Pnnt) Plumbv' Signature MPIMPRS Number Business Phone Number <br /> WADE RUFSHOLM O ^ Q 227691 715-3494286 <br /> Plumber's Address(Strat,City,State,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 <br /> VIII.Coun /De mrtdi Use Onl <br /> Approved 0 Disapproved IYnnit Pce Uma Issued Issuing Agent Signature <br /> ❑Owner Given Reason fur Uenixl <br /> 5 �7Z�00 Z � <br /> IX.Conditions of Approval/Reasons for Disapproval OEM <br /> D <br /> D NOV 5 2013 <br /> Au.<n m<amnhm oast mr m<.y,mm.aa sahmlr m mr caner,nary an r'•nr.nm In.mon n ns,a nnneany;��COUNTY <br /> BU <br /> ZONING <br />