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County <br /> Safety and Buildings Division <br /> i <br /> as �}} 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co,) <br /> Pt P.O. Box 7162 <br /> $ � Madison,WI 53707-7162 <br /> Sanitary Permit Application Slate 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 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 may be used for secondary d/Z <br /> purposes in accordance with the Privacy Law,s. 15.04(l m,Stats. <br /> I. Application Information-Please Print All Information <br /> Pro erty Owner's Name Parcel# (9 7 C. a ,2 <br /> p j O <br /> /, A�j ood o oo y omz3�o <br /> Property Owner's Mailing Address Property Location,�7,r::- <br /> �v�b Z C/ /---, 11/CJ' t/ 5�11 Govt.Lot_�— <br /> City,State/ Zip Code Phone Number y4, '/4, Section 45�7 <br /> C) <br /> .�:'C1Q 51dlr�,�' 9 ��13� (circle one <br /> II. pe of Buil/ding/(Check all that apply) / Lot# 7 D T_ N; R E or <br /> or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> �—. Block# <br /> ❑Public/Commercial-Describe Use �--- <br /> ❑ City of <br /> pL i1 1 <br /> El State Owned-Describe Use `-- CSM Numl�r 11 Village of <br /> 9�Town of �G-O <br /> IIL Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑New SystemReplacement System ❑ TreatmentfHolding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. El Permit Renewal /❑ 'Permit Revision ❑ Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> T e of POWTS S stem/Com onent/Device: Check all that apply) <br /> Non-Pressuri�sd 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.Dis ersal/Treat ent Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersa Area Proposed(so System Elevation <br /> ys0 `7 6 zl 3 7 1 <br /> VI.Tank Info Capac"Ta"nks <br /> tal #of Manufacturer <br /> Galllons Units <br /> New Tanks <br /> ctU 'i, y n wt7 ii <br /> Septic or HeWiag Tank- /ov v p <br /> Dosing Chamber /�a <br /> VII.Responsibility Statement- 1,the undekgned,assume responsibility for installation of the POWTS shown on the attacked plans. <br /> Plumber's Name(Print) Plumber's atur� MP/MPRS Number Business Phone Number <br /> WADE RUFSHOLM lz� 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 <br /> VIII.Court /De artment Use Only <br /> Permit Fee Date Issued Issuing Agent Signature <br /> ® Approved ❑Disapproved S 0s- <br /> 1\ ❑Owner Given Reason for Denial c1' <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> LC-ST— I= (43 Attach to complete plans for[he system and submit to the County only on paper not less than 8111 x 11 inches in size <br />