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ii:'r'at,,,,,,: County, <br /> %, Safety and Buildings Division /t <br /> 1400 E Washington Ave ary (tobyCo.) <br /> L, Sanit Permit Number be filled in Co. <br /> �. ' P.O.Box 7162 SPilli_ 20—((0 <br /> ' , .: Madison,WI 53707-7162 <br /> ' 6,51 —20 —117 <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 �+'����� <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 <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. Jr.-,,11-4/ e S <br /> /1) � �ftl <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# C' 7 G C 6 2 3 b'/7,2 47/ <br /> C- u 4- s-Aiyd e ' eV 000 v/yon" li sari. <br /> Property Owner's Mailing Address �j Property Location /0 C / <br /> L- / <br /> %3 7/6 5 7C5i I r= Govt.Lot <br /> City,State /( Zip Code PhoneNumber , C C� r /-SC y,,� y4, Section� 2 <br /> fi/�Cw .jt, V 1,7�� 30V-78/ 77 7! i T ,}8 N; R . circEoolic <br /> IIII.Type of Building(check all that apply) Lot# <br /> 1 I or 2 Family Dwelling-Number of Bedrooms 3 7 Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use ❑ City of '_-__ <br /> ❑State Owned-Describe Use CSM Number 0 Village of /� <br /> Val 7P'46-1-4.? <br /> P'46 1"� own of if)/4/1-2; £15 <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. hew System 0 Replacement System ❑Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(e(explain) <br /> 1B. 0 Permit Renewal ❑Permit Revision ❑ Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> TSV.Type of POWTS System/Component/Device: (Check all that apply) <br /> rXNon-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(at) Dispersal Area Proposed(st) System Elevation <br /> y30 / .7 v3s c' 9-5 <br /> VII.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units L''' <br /> o b <br /> New Tanks Existing Tanks L' 0 A E i .a 5 <br /> a. U co 5, re w C7 0, <br /> Septic or Heklitr�Palil< /e ew .�- /' A o J0 r &' P s c-c) 7�, <br /> Dosing Chamber C / /V <br /> VII.Responsibility Statement- .l,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature f MP/MPRS Number Business Phone Number <br /> WADE RUG /FSHOLM /�I G�_C'(fe `.{ 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 <br /> ��I L County/Department Use Only <br /> pproved ❑ Disapproved Permit Fee Date sued pent it 3 �❑ Owner Given Reason for Denial <br /> II ditW of A rova�e IA .ass fonOS <br /> -1:410444•4 iw6t k Ma <br /> IECEEIVE <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 xins A I�if11�U 2 1 J 2n20 <br /> SBD-6398(80313) M <br /> —"humett County <br /> Land Services Department <br />