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.,lf:Prariii„ . County <br /> "' �'• Safety and Buildings Division <br /> r, <br /> 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> P.O. Box 7162 -791 <br /> ,',;••. Madison,WI 53707-7162 <br /> \ <br /> \y0 SIU`n`••4�� <br /> "- <br /> Sanitary Permit Application State Transaction Number1 Q <br /> In accordance with SPS 383.21(2),Wis.Adm Code,submission of this form to the appropriate governmental unit G OV A,7'q /1 tl e w <br /> is required prior to obtaining a sanitary permit. Note:Application forms for state-owned POWTS are submitted to Project Address(if different than[nailing address) <br /> the Department of Safety and Professional Services. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. <br /> L Application Information-Please Print All Information a f3 <br /> Property Owner's Name Parcel# C O/cZ <br /> Y.3,5 e—e- 16- azo co 61 <br /> Property Owner's Mailing Address Property Location <br /> J 76 CY 1-14,4/tz 'WDD,-J C-J 1-C I'Q Govt.Lot <br /> City,State Zip Code Phone Number y4, /4, Section %3 <br /> y3 (circle one <br /> (j T�6_N; REore.) <br /> �x,1 J u� IS <br /> II.Type of B ilding(check all that apply) Lot# <br /> t�or 2 Family Dwelling-Number of Bedrooms 5-0 f 5� Subdivision Name <br /> Block# A c,�^,J /i �to Vi lam, <br /> ❑Public/Commercial-Describe Use 1 ❑ City of <br /> �- CSM Number ❑ Village of -� <br /> El State Owned-Describe Use C 5 d� <br /> Town of �/q <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑New System eplacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> List Previous Permit Number and Date Issued <br /> B. ElPermit Renewal 11Permit Revision ElChange of Plumber ❑Permit Transfer to New <br /> Before Expiration Owner <br /> IV.Type of POWTS S stem/Com onent/Device: Check all that apply) <br /> Non-Pressurized In-Ground ❑Pressurized In-Ground ❑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/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) D!Manufacturer <br /> rsal Area Proposed(sf) System Elevation <br /> Sb 7 Gy3 5 oG <br /> VI.Tank Info Capacity in Total #of <br /> Gallons Gallons Unitsv w •`-' <br /> New Tanks Existing Tanks o a`{ 2 B m <br /> Septic orgaklingT3W a('o d Dp <br /> Dosing Chamber �� Qd <br /> VIL Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signam MP/MPRS Number Business Phone Number <br /> WADE RUFSHOLM A yam-_ 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) Gt�- <br /> PO BOX 514,SIREN,WI 54872 <br /> III.County/Department Use Only <br /> Approved ❑ Disapproved Permit Fee O D�aite Issued` / Issuing Agent Sign re <br /> 9 1 <br /> ❑ Owner Given Reason for Denial 1 <br /> $3 7S <br /> AL Conditions of Approval/Reasons for Disapproval <br /> ECEIVEnn <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8Rlh <br /> 13URNETTCOUNTY <br /> ZONING <br />