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Co f <br /> 4 <br /> unt f/ <br /> Safety and Buildings Division al+ Qi/ _ <br /> 1400 E Washington Ave <br /> 9 Sanitary Permit Number(to be filled in by Co.) <br /> P.O.Box7162 nn,, `` <br /> Madison,WI 53707-7162 A' j` [q 2� <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit 6,10430 <br /> is required prior to obtaining a sanitary permit. Note:Application forms for state-owned PO WTS are submitted to Project Address rf differgnt than ma1 g address) <br /> the Department of Safety and Professional Services. Personal information you provide may be used for secondary �� G� G✓i �? C1 CA-) <br /> purposes in accordance with the Privacy Law,s.15.04(1)m,Stats p <br /> 1. Application Information-Please Print All Information c_ R c <br /> Property Owner's Name Parcel# ('-`7 D�2 n F2 yO 16 n J <br /> Property Owner's Mailing Address Property Location <br /> Govt.Lot <br /> City,State Zip Code Phone Number y, 1/4, Section—� <br /> ` ,`jo r,i,�e.e Ak S 371 <br /> �/ circle one <br /> ER.Type of Bui➢ding(checkal➢that apply) Lot# T 7C N; R E oW) <br /> or 2 Family Dwelling-Number of Bedrooms { Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> ❑ <br /> El State Owned-Describe Use CSM Number Village of <br /> VP 1 q -0-Townof (5�A �-��C <br /> 111.Type of Permit: (Check only one box on line A. Complete Hine B if applicable) <br /> A. ❑New System Replacement System` - ❑ TreatmenUHolding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> I <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 /> ➢V.Type of iPOWTS System/Component/Device: (Check all that a ➢ <br /> don-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 IInforanation: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> WWII.Tank Info Capacity in Total #of Manufacturer u <br /> I Gallons Gallons Units o <br /> New Tanks Existing Tanks o B L <br /> Septic or Hoktiag-T-m l< <br /> Dosing Chamber <br /> VIE.Responsibility Statement- 11,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 i� Oj� 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 <br /> VVIIIII.Conant /®e artment Use Only <br /> `Approved Disapproved Permit Fee 00 Date I ued Is Agent Sr afore <br /> ❑ Owner Given Reason for Denial <br /> 3�S !o ��g atiu <br /> EX.Conditions of Approval/Reasons for Disapproval <br /> iA 2 &CC e, rejaw-s ! vwf s I otte.ruf.on �jpe_ -j6r <br /> eou sect. OCT 2 1 2019 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x t 1 inches in size urnett ounty <br /> Land Services Department <br /> SBD-6398(R0313) � , ' —V U Ca <br />