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��rAPTII[t.T County <br /> Safety and Buildings Division BURNETf <br /> 0 S 201 W.Washington Ave., P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> $ , Madison,WI 53707-7162 �l 7 <br /> .� y 5551/3 0 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate govemmental unit ;Z17929(o 03 <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 Servies. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s. 15. 1 m,Stars. <br /> L Application Information-Please Print All Information <br /> Property Owner'y Namen� /[� (/JJ"� r' Parcel N o 7-O/ - '/5 - 0 7-5 <br /> (Ar r✓ e1r\ V 2S C>'S-00 SI -O�Z o000 <br /> Property Owner's Mailing Address -yl---�� I r Property Location e�2 e4 5�� L / /V C Govt.Lot C5- <br /> City,State Zip Code Phone Number �, <br /> JJ �j /., /, Section <br /> /141A) e' In A�, Jrs-t>/5// O �(ctrole one),,. <br /> II.Type of Building(check all that apply) Lot 8 T u N; R S E o <br /> ,15-1 or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> _ Block M <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number �j ❑Village of '--r- <br /> 1/s�? I J}-Town of <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) _ C <br /> A' ❑New System KReplacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System Comonent(Device: Check all that apply) <br /> ❑Non-Pressurized In-Ground ❑ Pressurized In-Cmrund ❑ At-Grade 19 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 ersaUTreatment Area Information: <br /> Design Flog) Design Soil plication Rate(gpdsf) Dispersal Area Required(si) Dispersal A roposed(st) System Elevation <br /> z-/ y ys z <br /> VI.Tank Info Capacity in Total N of Manufacturer <br /> Gallons Gallons Units u p <br /> New Tanks Existing Tanks w o $ 3 <br /> cL U n rn a.0 P.. <br /> Septic or 14@1&.e =k ! o() C) <br /> 744 <br /> Dosing Chamber 6 .5--c <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plana. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> WADE RUFSHOLM ! I A 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> P.O.BOX 514,SIREN WI 54872 <br /> V11L Court /De artment Use on] <br /> Permit Fee Date Issued Issuing Signature$ <br /> Approved ❑Disapproved ,gyp <br /> El Owner Given Reason for Dcnial 3 75'ts 3' er,O/Z <br /> IX.Conditions of ApprovaUReasons for Disapproval D E 11SE <br /> NOV 2 9 2012 <br /> Atnch to comoletestam for the system mad submit to the County only on naotr not less than 8 Ut x 1MAWTT COUNTY <br /> ZONING <br />