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, -k ii <br />Safety and Buildings Division <br />County ifX <br />opt,( / i 111 <br />1400 E Washington Ave <br />Sanitary Permit Number (to be filled in by Co.) <br />P.O. Box 7162 <br />j iA <br />$ % ' <br />Madison, WI 53707-7162 <br />Sanitary Permit Application <br />State Transaction Number <br />/y//1 <br />In accordance with SPS 383.21(2), Wis. Adm Code, submission of this form to the appropriate governmental unit <br />Project Address (if different than mailing address) <br />is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are submitted to <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 />r r <br />—3 y 7 j` 3 177 , /e- l j <br />Parcel # <br />I. Application Information – Please Print All Information <br />Property Owner's Name <br />g ,— 1 +d k1n <br />Property Owner's Mailin Address <br />Property Location <br />( <br />a :3C/ AJ / �! <br />Govt. Lot <br />1/4j /4, Section 141 <br />City, State <br />[-ZipCode Phone <br />-3r/� <br />Number <br />-5'/ J <br />circle one] ._ <br />TLEo W <br />N; R/ <br />II. 'Type of Building (check all that apply) Lot# <br />a <br />Subdivision Name <br />�(,a,;_,�( <br />I c %/ <br /># <br />Block <br />szt'�1Ior2FamilyDwelling—NumberofBedrooms <br />(A% <br />❑ City of <br />❑ Public/Commercial — Describe Use <br />❑ State Owned — Describe Use CSM <br />❑ Village of <br />ATown of <br />Number <br />_ <br />III. 'Type of Permit: (Check only one box on line A. Complete line B if applicable) <br />A, <br />❑ New System <br />.placement System <br />❑ 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 />—SQ <br />TV. Type of POWTS System/Component/Device: Check all that apply) <br />11Ion-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) <br />Design Soil Application Rate(gpdsf) <br />Dispersal Area Required (soDispersal <br />Area Proposed (so System <br />Elevation <br />VI. Tank Info <br />Capacity in Total <br /># of Manufacturer <br />y c <br />Gallons Gallons <br />Units <br />a <br />1 <br />New Tanks <br />Existing Tanks <br />Septic or <br />Dosing Chamber <br />VII. Responsibility Statement- 4 the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. <br />Plumber's Name (Print) <br />Plumber's Signa <br />MP/MFRS Number <br />Business Phone Number <br />WADE RUFSHOLM <br />f _ %� <br />�/(d <br />227691 <br />715-349-7286 <br />Plumber's Address (Street, City, State, Zip Code) <br />PO BOX 514, SIREN, WI 54872 <br />VIIY. Cour /De artment Use Only <br />Approved <br />❑Disapproved <br />—PermitFeeDO <br />$ <br />Date Issued <br />Issuing Agent Signator <br />h <br />3 / � <br />Q' <br />l - I <br />Owner Given Reason for Denial <br />El�S <br />V <br />easons for Disapproval <br />�Apfiffl <br />DECEPVE <br />Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x nut size U <br />OCT 0 2 2018 <br />SBD -6398 (80313) <br />13URNETT COUNTY <br />ZONING <br />