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�'Cr �rrirT <br />°` <br />I <br />Safety and Buildings Division <br />County <br />iV �Jr <br />\ t <br />r�; <br />1400 E Washington Ave <br />Sanitary permit Number (to be filled in by Co.) <br />j< <br />P I <br />P.O. Box 7162 <br />SAN -18 - 9 3 <br />Madison, WI 53707-7162 <br />�oa�9 <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 />O S� <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 />/ <br />purposes in accordance with the Privacy Law, s. 15. I m), Stats. <br />/ r� <br />1. Application Information — Please Print All Information <br />Property O r':&Name <br />-e <br />Parcel # 7 ,Z / <br />7 -3d Pe-fier5 ,d <br />' er, 6-e� 0 -3 U 17 owc0 <br />Property Owner's Mailing Address <br />Property Location <br />> <br />033 E'_ S Yl1 L <br />0 a <br />Govt Lot 3 <br />�/. '/4, Section <br />City, State <br />Zip Code <br />Phone Number <br />L fii � �� Rte :7 <br />5 cl 3 <br />��TT <br />6 1 �a� 30� <br />circle one <br />T_ " L� N, R Eo .D <br />U. Type of Building (check all that apply) <br />Lot <br />( or 2 Family Dwelling — Number of Bedrooms <br />Subdivision Name <br />Block # <br />❑ Public/Commercial — Describe Use <br />—'-- <br />❑ City of <br />❑ State Owned — Describe Use �~ <br />❑ Village of <br />CSM Number <br />J ) <br />y / ` <br />(Town of S V If <br />III. Type of Permit: (Check only one box on line A. Complete line B iif/appli ble) <br />A. <br />(ONew System ys <br />❑Replacement System <br />❑ Treatment/Holding Tank Replacement Only <br />❑Other Modification to Existing System (explain) <br />B. <br />❑ Permit Renewal <br />Before Expiration <br />❑ Permit Revision <br />❑ Change of Plumber <br />❑ Permit Transfer to New <br />Owner <br />List Previous Permit Number and Date Issued <br />IV. Type <br />of POWTS S stem/Com onent/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. Dispersal/Treat ent Area Information: <br />Design Flow (gpd) <br />Design Soil Application Rate(gpdsf) <br />Dispersal Area Required (sf) <br />Dispersal Area Proposed (st) <br />System Elevation <br />VI. Tank Info <br />Capacity in <br />Total # of Manufacturer <br />Gallons <br />Gallons Units <br />o <br />o <br />New Tanks Existing Tanks <br />oY <br />R <br />al <br />a U <br />rn h rn w <br />Septic or Holdmg5,vk <br />o .r - <br />C t <br />Dosing Chamber <br />C) - <br />oUV 1L <br />VII. Responsibility Statement- 1, 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 <br />Business Phone Number <br />WADE RUFSHOLM <br />y <br />227691 <br />715-349-7286 <br />Plumber's Address (Sheet, City, State, Zip Code) <br />PO BOX 514, SIREN, WI 54872 <br />VIII. CountyODepartment Use Only <br />Approved <br />Disapproved <br />Permit Fee <br />Date Issued <br />Issuing Agent Sign <br />❑ Owner Given Reasonfor DenialAFFRfff <br />D-Lm7easons for Disapproval D <br />JUL 0 2 2018 OD <br />Attach to complete plans for the system and submit to the County only on paper not less than 8 in x 11 inches inaW RNETT COU NTY <br />ZONING <br />