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C�nr1�` <br />County <br />Safety and Buildings Division <br />1400 E Washington Ave <br />Sanitary Permit Number (to be filled in by Co.) <br />I <br />P.O. Box 7162 <br />f: l=' <br />!p�s�gj <br />Madison, WI 53707-7162 <br />Q5 <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 />is required prior to obtaining a sanitary permit Note: Application forms for state-owned POWTS are submitted to <br />N A <br />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), Stats. <br />` �l / 6 Id 5-A4 I- <br />1. Application Information - Please Print All Information <br />Property Owner's Name( <br />Parcel # 0 7 0 �- _ (,/ p -t =!•/ / <br />Property Owner'§ Mailing Address <br />Property Location e C <br />9� 76 5 r+ry t A � <br />Govt Lot z <br />yA, '/4, Section _// <br />City, State <br />Zip Code <br />Phone Number <br />iU ,wti� .� <br />5-0 3 3 <br />— <br />(circle one <br />T Vo N, R E or <br />U. Type of $tail ng (check all that apply) <br />Lot # <br />Subdivision Name <br />or 2 Family Dwelling - Number of Bedrooms <br />I <br />Block # <br />D Public/Commercial - Describe Use �� <br />�-- <br />D City of '"-- <br />D State Owned - Describe Use <br />D Village of <br />CSM Number <br />V f 7 A /5--1- <br />P'own of �a22-7 <br />III. Type of Permit: (Check only one box on line A. Complete line B if applicable) <br />A. <br />D New System <br />Replacement System <br />D Treatment/Holding Tank Replacement Only <br />D Other Modification to Existing System (explain) <br />B. <br />D Permit Renewal <br />D Permit Revision <br />D Change of Plumber <br />D Permit Transfer to New <br />List Previous Permit Number and Date Issued <br />Before Expiration <br />Owner <br />AM <br />IV. rype of PO'ATS S stem/Com onentlDevice: Check all that apply) <br />$Non -Pressurized In -Ground ❑ Pressurized in -Ground ❑ At -Grade ❑ Mound > 24 in. of suitable soil D Mound < 24 in. of suitable soil <br />D Holding Tank D Other Dispersal Component (explain) D Pretreatment Device (explain) <br />V. Dispersal/Treatment 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 />C5 <br />7 <br />VI. Tank Info <br />Capacity in <br />Total # of Manufacturer <br />Gallons <br />Gallons Units J, <br />Uo <br />New Tanks Existing Tanks <br />o <br />a U <br />R <br />rn oa is. C7 <br />a <br />Septic or k <br />r t <br />Dosing chamber <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 />WADE RUFSHOLM <br />Plumber's Signature �J <br />/ <br />MP/MPRS Number <br />227691 <br />Business Phone Number <br />715-349-7286 <br />,r / // <br />Plumber's Address (Street, City, State, Zip Code) <br />PO BOX 514, SIREN, WI 54872 <br />Cour /De artment Use Only <br />Approved <br />El Disapproved <br />Permit Fee <br />$ OD <br />Date Issued <br />Issuing Agent Sign <br />ElOwaer Given Reason for Denial <br />714 <br />Conditions of Approval/Reasons for Disapproval <br />VAYkl8 <br />2018 <br />Attach to complete plans for the system and submit to the County only on paper not less than a r2 z AA rIN e � <br />yysliM�M <br />