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County, <br /> - Safety and Buildings Division >�'c.iI-Alt t_,'- <br /> y S.D. - 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> Madison,WI 53707-7162 �► n. f�2 21 <br /> iTl�+ old, <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 Servies. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# Cc 7 0 `/d a aye%y <br /> Bri.lai2' '1 -% 142 6 ✓c3`.ea La; c/3UC7Cj <br /> Property Owner's Mailing AddreSS Property Location .i <br /> 02 Z 7.5"3 c i fr€y A✓>T e r R e/ Govt.Lot t2 <br /> City,State Zip Code Phone Number , <br /> G �y_I / g j 9 /4, /4, Section <br /> r!1 N I.S C.N ,-ci/ (A I 151 rJ ' C �Jt 3 T N; R I <br /> circlE one <br /> IL Type of Building(efleck all that apply) Lot# <br /> ? or 2 Family Dwelling-Number of Bedrooms 3 / / i1) Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use "" <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM <br /> Number�J %'71 ❑ Village of <br /> Pi Town of actcs R,'I)et-, <br /> I <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A <br /> ❑New System 0 Replacement System X Treatment/Holding Tank Replacement Only 0 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 /> IV.Type of POWTS System/Component/Device: (Check all that apply) <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 /> IV.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) I Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> VI.Tank Info I Capacity in Total • #of Manufacturer I <br /> Gallons Gallons Units az 2 o u <br /> New Tanks I Existing Tanks a�ai o E .o = <br /> I at U iA v vi 4- CD fp.. <br /> Septic or ` '' 'Tank I //t ni 0 ,4'f/l% l ip 0 f Wes c-e, (----" <br /> Dosing Chamber <br /> 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 RUTSHOLM 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 /> Permit Fee Date Issued Is in ent Si <br /> Approved , ❑ Disapproved 2 C� / <br /> Owner Given Reason for Denial S 3 75 g/31 IV <br /> r ._i <br /> I�b.Conditions of A proval/Reasons for Disa proval � tE 0r E 11 V IE <br /> Needs ;n�e�t e qn� k Crass oci iLIciI I-_-.) <br /> Meer- a(( 3'1�°% AUG 3 0 2022 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 Y2 x 11 L.—,;. <br /> IJUMett County <br /> Land Services Department <br /> SBD-6398(R. I I/I I) <br />