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... xaa_r,t ;:_.. County <br /> V4:. Safety and Buildings Division 4c!/1/1.)( <br /> 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> -,,,, ;:"I P.O.Box 7162 S 20 - 1.9 ce <br /> Madison,WI 53707-7162 _ <br /> /l C.,�T/ l — /7 q <br /> Sanitary Permit Applicata® State Transaction Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit W�vv�� <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 /> 1the Department of Safety and Professional Services. Personal information you provide may be used for secondary � <br /> 7/S7p 4../9.:5 � f` <br /> 1 purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. <br /> I. Application Information-Please Print MI Information <br /> Property Owner's Name Por„, .J .5-05- <br /> Parcel# c, 7 03,2 �? 5// /-5`off.E <br /> V �5G/3 P c . c, ocr2 0/070.06 <br /> I Property Owner's Mailing Address Property Location/0 c,/ It�7 14^16 <br /> .5—‘ /q l Air/t ie_ Ai Govt.Lot v2'�3 i�'!r0��+ <br /> City,State Zip Code Phone Number yq ...2.4.p`-//4/ <br /> 1- / �/ f 'A, Section <br /> /7 /4'1 5-5-S0 c/ vz/t7�j `- T© 7-7/7 ert�/ _(circle one <br /> II.Type of Building(check all that apply) Lot# T / N; R/ E o W <br /> l.or 2 Family Dwelling-Number of Bedrooms . t� Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> ri� <br /> 0 State Owned-Describe Use yCSMNumber �/ 0Village of <br /> V / p', 47',S Town of -5-.4"i'115 <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. 0 New System a lacement System y p y 0 Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> B. 0 Permit Renewal ❑Permit Revision ❑ Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration I Owner <br /> IIV.'Type of POWTS System/Co1njlonent/Device: (Check all that apply) <br /> .Non-Pressurized In-Ground 0 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(sf) Dispersal Area Proposed(sf) System Elevation <br /> 7.S 0 , 7 / 0 7,2 i/00 . �j. , 7 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o bu <br /> 1 New Tanks Existing Tanks B o y 2 0 m <br /> c. U ; rn w C7 a, <br /> Septic orHe4di+x k /000 7s d 175-6 ..t i)c1-4.0 ?SCc fW'le.S<r -f--- 7z— <br /> ` J <br /> fDosing Chamber <br /> I 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 c.�L A` ''`'4 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) � <br /> PO BOX 514,SIREN,WI 54872 <br /> VIII.County/Department Use Only <br /> Approved ❑ Disapproved $PermitDat9e�ued 4 nt Signat\ur <br /> l ❑ Owner Given Reason for Denial //-/jam <br /> IX.Conditions of Approval/Reasons for Disapproval L' i; j 5,4 - <br /> OR 1OW$ IoG /CWei &Kd K*!- (4,44' Ow COI/KceS• 2` V —1 <br /> 13.1F} of Space. ?a.'t eg,( ptroe�tu Gfs• D l5 q <br /> PI 1>faitS ek, %MAS•t be 60ff chews& mat ulcus_ <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1A 11 1:hes srlai <br /> UV�. <br /> 9 2 O J <br /> SBD-6398(R0313) v <br /> rurnett County <br /> Land Services Department <br />