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E <br />Attach to complete plans for the system and submit to the %.oanty only on paper not less roan o uz a It in— .0 a..c <br />Safety and Buildings Division <br />County <br />,9C', <br />it <br />` <br />1400 E Washington Ave <br />Sanitary Permit Num (to be filled in by Co. <br />�ber <br />- p i=j <br />P-O. Box 7162 <br />WI 53707-7162 <br />S N g 5-y <br />?' <br />Madison, <br />_ <br />b Q <br />c <br />Sanitary Permit Application <br />State Transaction Number <br />In accordance with SPS 38321(2), Wis- Adm. Code, submission of this form to the appropriate governmental unit <br />Note: Application forms for state-owned POWTS are submitted to <br />Project Address (if different than mailing address) <br />is required prior to obtaining a sanitary permit- <br />the Department of Safety and Professional Services. Personal information you provide may be used for secondary <br />36 9 <br />purposes in accordance with the Privacy Law, s. 15.0 I m), Stats. <br />2� r` /- / C G 0,-. <br />u <br />Parcel # Q -'la -,� -yam /S--/ ? S' <br />I. Application Information - Please ]Print All Information <br />Property Owner's Name <br />r k <br />/� <br />Property Owner's Mailing Addrests <br />Property Location <br />97-51 lD K, ►� IC ��,�� <br />Govt. Lot <br />y. t/., Section /Y <br />City, State <br />Zip Code <br />Phone Number <br />q1 <br />//� �/� �/v r <br />q <br />5J 7 4 / <br />Q <br />7f73 " 3SS� /v <br />turtle one <br />T _ N; R E ok�W� <br />H. Type of Building (check all that apply) <br />Lot # <br />Subdivision Name <br />❑ I or 2 Family Dwelling - Number of Bedrooms <br />d9 I I �' / <br />C e L D e AJ U "' lam, <br />Block # <br />❑ City of `�— <br />❑ Public/Commercial - Describe Use <br />�- <br />El Village of <br />CSM Number <br />❑State Owned -Describe Use <br />�---15rTownf <br />T <br />V AGO <br />III. Type of Permit: (Check only one box on line A. Complete line)13 if applicable) <br />A, <br />❑ New System <br />❑ Replacement System <br />K Treatment/Holding Tank Replacement Only <br />❑ Other Modification to Existing System (explain) <br />B. <br />❑ Permit Renewal <br />❑Permit Revision <br />❑ Change of Plumber <br />❑ Permit Transfer to New <br />List Previous Permit Number and Date Issued <br />Before Expiration <br />Owner <br />�///,5 <br />IV. Type <br />of POWTS S stem/Com onent/Device: Check all that apply) <br />2rNon-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/Treat ent Area Information: <br />Design Flow (gpd) <br />Design Soil Application Rate(gpdsf) <br />Dispersal Area Required (st) <br />Dispersal Area Proposed (st) <br />System Elevation <br />3 Qo <br />VI. Tank Info <br />Capacity in <br />Total <br /># of Manufacturer <br />zf <br />Gallons <br />Gallons <br />Units �? <br />J°'a,, .2 m <br />New Tanks Existing Tanks <br />ai o 2 2 R <br />65 rn v. 0 r1. <br />Septic or kiekting'fft <br />Dosing Chamber <br />VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. <br />Plumber's Name (Print) <br />Plumber's Signature <br />MP/MPRS Number�715-349-7286 <br />ber <br />WADE RUFSHOLM <br />/ n <br />ljil �G— <br />227691 <br />Plumber's Address (Street, City, State, Zip Code) <br />PO BOX 514, SIREN, WI 54872 <br />Colin /De artment Use Only <br />Approved <br />❑ Disapproved <br />Perm?it Fee 040Date <br />$ <br />Issued <br />Issuing Agent Sign <br />El Owner Given Reason for Denial <br />`7 7S' <br />S r 30 <br />IX. Conditions of Approval/Reasons for Disapproval <br />WS-led A <br />"PROVED <br />Ivzj <br />r telne&4 <br />Attach to complete plans for the system and submit to the %.oanty only on paper not less roan o uz a It in— .0 a..c <br />