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c+ ri�� . <br />�• COMPUTER/SCANNED Safety and Buildings Division <br />County <br />!q j •. i' 1400 E Washington Ave <br />Sanitary Permit Number (to be filled in by Co.) <br />S j= P.O. Box 7162 <br />Madison, WI 53707-7162 <br />Sanitary Permit Application <br />State Transaction NumberN� <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 (ii differen 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 />-L <br />purposes in accordance with the Privacy Law, s. 15.04(1)(m), Stats. <br />7a ��1Td w <br />Parcel # p 7" x.2--3 <br />I. Application Information -)Please )Print All Information <br />Property Owner's Name <br />I <br />PMdGci <br />6/- o -© O 0 <br />Property Owner's Mailing Address <br />Property Location <br />PC> O <br />Govt. Lot <br />45 /4 /p,,2: �/., Section <br />City, State <br />Zip Code <br />Phone Number <br />G� <br />SCIS 93 <br />1220 _� M <br />(circle one <br />H. Type of Building (check all that apply) <br />Lot # <br />Subdivision Name <br />or 2 Family Dwelling - Number of Bedrooms <br />—' " <br />Block It <br />11 City of <br />❑ Public/Commercial - Describe Use <br />�- <br />11 State Owned - Describe Use <br />❑ Village of <br />1 <br />CSM Number <br />-- <br />P?,Town of <br />III. Type of Permit: (Check only one box on line A. Complete line B if applicable) <br />A. <br />'KNew Systemp <br />System <br />❑ Replacement S tem <br />❑ Treatrnent/Holdin Tank Replacement Only <br />g P <br />0 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 />IV. Type <br />of POWTS System/Component/Device: Check all that apply) <br />P,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/Treatment Area Information: <br />Design Flow (gpd) <br />Design Soil Application Rate(gpdsf) <br />Dispersal Area Required (sf) <br />Dispersal Area Proposed (sf) <br />System Elevation <br />ori <br />ov <br />VI. Tank Info <br />Capacity in <br />Total # of Manufacturer <br />Gallons <br />Gallons Units S, L <br />of v U v y <br />y <br />New Tanks Existing Tanks <br />o <br />a. v n y va is c7 <br />a <br />Septic or lioislingifaek <br />`AJ <br />D ©t/ <br />D l / � e-s C r) <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 />Plumber's Signature <br />MPMIPRS Number <br />Business Phone Number <br />WADE RUFSHOLM <br />`�- <br />(/ <br />227691 <br />715-349-7286 <br />Plumber's Address (Street, City, State, Zip Code) <br />PO BOX 514, SIREN, WI 54872 <br />II. Coun /De artment Use Only <br />Approved <br />❑ Disapproved <br />Permit Fee B <br />D <br />Date Issued <br />Issuing Agent Sign <br />11 Owner Given Reason for Denial <br />3 7S <br />Q� <br />7� <br />S- - i U <br />IX. Conditions of Approval//Reasons for Disapproval �/ z (� <br />/GO/" <br />/v0 Gf/P�G `OCA/ i0ly OSfr/I Oiv (� <br />/ G aN> r L!a �D <br />i <br />I A A A A R <br />Attach to complete plans for the system and submit to the County only on paper not less than 8 in x 11 inches in siagA 1 V L ZU15 ! I �� <br />OURNETTCOUNTY{(--�// <br />ZONING <br />