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Safety and Buildings Division �r�i� <br /> 1 � i <br /> 9 Sanitary Permit Numbe (to be filled in by Co.) <br /> sP 1400 E Washington Ave <br /> �; P.O. Box 7162 � <br /> Madison,WI 53707-7162 <br /> Sanitary Permit Application State 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 <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Slats. <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> v `/a2 o7-31 /tea 7 <br /> 2 y�v oe Y4 5"/S�5' oaeoatT <br /> Propertyer''ssMa'I' Address Property Location <br /> Govt Lot <br /> City,State Zip Code Phone Number /ar <br /> D , /a, Section <br /> /)oc e 4e(- /V a jy SJR (circle one <br /> ,00T -73 N, R 1�E or( <br /> It.Type of Building(check all that apply) Lot# <br /> 04 or2Family Dwelling-Number ofBedrooms I;Z Subdivision Name �> <br /> Block# I J- s G�� JS <br /> ❑Public/Comntercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of / J <br /> Town of (iVno :! /U p-+^ <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑New System ❑ Replacement System A Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal El Permit Revision El Change of Plumber <br /> ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> W.Type of POWTS System/Component/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.Dis ersailTreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(st) Dispersal Area Proposed(sf) System Elevation <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o <br /> New Tanks Existing Tanks w c aUi `= y ;; r <br /> Septic or Holding Tank �} 60 Z <br /> Dosing Chamber m0 r DD <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> WADE RUFSHOLM �•f ,/� 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 <br /> VIII.Coun /De artment Use Onlyproved ❑ DiRapp roved <br /> Permit Fee Date Issued I uing Agent Signature <br /> ''') � � - <br /> ❑ Owner Given Reason for Denial $ 3 -2-S J 3 J S3 ) rj <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attadt to complete plans for the system and submit to the County only an paper not less than 81/2x 11 inches in size <br />