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•`y,,i r..iRjr., County <br /> Safety and Buildings Division of ti.) •c2- <br /> :! 'I,'. 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> P.O.Box 7162 Iii.r4_0.1) <br /> Madison,WI 53707-7162 <br /> , 42 1343 <br /> Sanitary Permit ppl cation State TransactionNumb� <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 3i azy y 4704 FDIC 7-?../ <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. \ <br /> I. Application Information-Please Print MI Information Cbl' 1 L 021b7;,7-9 <br /> Property Owner's Name Parcel# n 7 Q 3 2 .2 SI/it. 'j <br /> L.. e o S/+r">/,/n ;-c-> �;i CUO f C�//UO[) <br /> Property Owner's Mailing Address Property Location /24 / <br /> 3/OC) 4/ R Frig i/ Govt.Lot <br /> City,State Zip Code Phone Number y, <br /> /< /3 <br /> , Section <br /> b n/j)t q 1.7 /A/. `� / J e) 7/5‘C‘--Y5.2 i.e <br /> Ii.Type of Building(check all that apply) Lot# T Vi/ N; R j� E jh1 <br /> or 2 Family Dwelling-Number of Bedrooms <br /> Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use r <br /> 0 City of _ <br /> State Owned-Describe Use CSM Number 0 Village of <br /> �_ ,Town of --5-eci i_S 5 <br /> EU.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. 0 New System Xna lacement System <br /> 0 Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> i <br /> 1B. I 0 Permit Renewal 0 Permit Revision 0 Change of Plumber 0 Permit Transfer to New List Previous Permit Number and Date Issued <br /> I1 Before Expiration Owner <br /> liv.Type of POWTS System/Component/Device: (Check all that apply) <br /> ,'Non-Pressurized In-Ground 0 Pressurized In-Ground 0 At-Grade 0 Mound>24 in.of suitable soil 0 Mound<24 in.of suitable soil <br /> 0 Holding Tank ❑Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> V.Dispersal/'II'reatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> 30 0 / 7 y 9 Vs 7‘,/ <br /> VI.Tank Info Capacity in Total #of Manufacturer t> <br /> Gallons Gallons Units 1, 5 o p <br /> New Tanks Existing Tanks o a s -c' R c <br /> c. 0 in y rn .til: C..7 0, <br /> Septic or Holding Tank 757, <br /> G- // G- / ,,,, �-_-; r 74--Dosing Chamber <br /> I <br /> i VIII.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 A MP/MPRS Number Business Phone Number <br /> WADE RUFSHOLM <br /> /(47,--e/e-- <br /> am/ e ��_ 227691 715-349-7286 <br /> ,f ljrj'a7(�`G'` <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 Permit Fee ..--- <br /> DateGued Issuing4.1 <br /> Arnt Si tore <br /> i ❑ Owner Given Reason for Denial $ 7� / 2�/�17 �✓ge <br /> Ib.Conditions of Approv 0/Re sons for Disapproval C9 r` I�'/,/,�`` *375 <br /> 0/4 _se)/' ester �-{ `cV 1 <br /> ECEEIVIE <br /> • <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/21.Iii hes in`9tE p 2 1 2020 <br /> SBD-6398(R0313) tilirtttstt County A <br /> Land Services Department <br />