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t1 a ,i, County <br /> Safety and Buildings Division I&("ti <br /> D yy 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> P.O. Box 7162 <br /> Madison,W 153707-7162 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of tlus 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 Project Address(if different than mailing address) <br /> the Department of Safety and Professional Services. Personal information you provide may be used for secondary q D © �j <br /> purposes in accordance with the PrivacyLaw,s.15.04 1 m,Stats. ! C> <br /> I. Application Information-Please Print All Information G, ,/i, -,� <br /> Property Owner's Name Parcel# c,,J Cs.z p 96 /6 C' 7 <br /> ( <br /> Property Owner's Mailing Address Property Location <br /> C <br /> 70 cJ /u r. Govt.Lot <br /> City,State <br /> Zip Code Phone Number y, /,, Section 7 <br /> C'ti k A- PA-t m i{ J 3�l ��.2� �/—CAL>:. 7 T _N, R/!,(Ele one)_ <br /> II.Type of Buildin (check all that apply) Lot# <br /> Xl or 2 Family Dwelling-Number of Bedrooms 1-2 3 Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use ❑City of <br /> CSM Number El Village of <br /> ElState Owned-Describe Use <br /> -Town off'' <br /> III.Type of Permit: (Check only one box online A. Complete line B if applicable) <br /> A. ❑ New System Replacement System g p Y g Y (explain) <br /> ) <br /> ❑ Treatment/Holding Tank Replacement Only El Modification to Existing System ex lain <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/Component/Device: (Check all that apply) <br /> 'PfNon-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) Design Soil Application Rate(gpdsf) Dispersal <br /> Are`a�Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> o l' <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o b <br /> New Tanks Existing Tanks <br /> J Y R <br /> Septic or HokhngTrnk'' <br /> Dosing Chamber <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> WADE RUFSHOLM / 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 <br /> VIII.Count /De artment Use Only <br /> pproved El Disapproved Permit Fee Date Issued Issuing Agent Si <br /> ❑ Owner Given Reason for Denial $ �345 " ' <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> � �- 3 � . � o�(I��s off' -��-�-�m�.,�—�-' -��.►.,� I� R,.�;;; # ti �Q'r`� <br /> gumett County <br /> ttach to complete plans for the 4st ' sub oun�fon y paper not less than 8 ill <br /> / 111 inctorM OerviceS Department <br /> SBD-6398(R0313) \57/6 / <br />