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County <br /> Safety and Buildings Division <br /> 1400 E Washington Ave <br /> " 9 Sanitary Permit Number(to be filled in by Co.) <br /> P.O. Box 7162 cJ� t ? <br /> Madison,WI 53707-7162 J ` 9 <br /> umb <br /> Sanitary Permit Application State Transaction <br /> r <br /> � <br /> In accordance with SPS 383.21(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 Project Addrr s(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 PrivacyLaw,s.15.04 1 m,Stats. <br /> 1. Application Information—Please Print All Information AA <br /> Property Owner's Name Parcel# 0 7 p 3;Z -2 5t/ 16 )t; <br /> hre_xc Z ec` 0. 060 a 100 :f�ai834 <br /> Property Owner's Mailing Address Property Location ,0 4,,I <br /> p.,,C 3 0 Govt.Lot <br /> City,State Zip Code Phone Number IV k l /4 s,C' 14, Section J_ <br /> A j)it N/N C) 7Yl ®71 11— (circle one <br /> 11.Type of Bali➢ ing(check all that apply) ! Lot# T !Y/ _N; R E o 2U <br /> N:y Subdivision Name <br /> Lor 2 Family Dwelling-Number of Bedrooms <br /> Block# <br /> ❑Pubiic/Conunercial-Describe Use ❑ City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of <br /> V�2 6, /n 1,7_ Town of sc,, <br /> 111.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A.A' ❑New System Replacement System <br /> y � p y ❑Treatment/Holding Tank Replacement Only El Other Modification to Existing System(explain) <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 /> , <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/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(so Dispersal Area Proposed(so System Elevation <br /> mod . 7 29� y�, 3 <br /> V1.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o <br /> New Tanks Existing Tanks o <br /> aU � cn wc7 a <br /> Septic or HokUmg-Tank /0 <br /> 00 <br /> —� e_ f;G 40 <br /> Dosing Chamber ! <br /> VIE.}responsibility Statement- 1,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 /> NVIIIIII.Ooun /➢fie artment Use Only <br /> pproved ❑Disapproved Permit Fee �7�1 <br /> sued Q sui Agent Si ture <br /> ❑ Owner Given Reason for Denial $3-75 1V <br /> EX.Oo itions of A prov�E al/IIBeasons for Disapproval Lt a-5- <br /> PP g. k of <br /> D <br /> D <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2MLand <br /> 2 0 Ut <br /> SBD-6398(R0313) <br /> nett County <br /> vices Department <br />