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Counrv- <br /> It <br /> Safety and Buildings Division <br /> 1400 E Washington Ave <br /> 9t Sanitary Permit Number(to be hued in by Co.) <br /> P.O. Box 7162 7,C/ / <br /> Madison,W1 53707-7162 �bD <br /> 34 <br /> `zss o31 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 38321(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit <br /> is required prior to obtaining a sanitary permit Note:Application forts 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 3/9� <br /> purpos in accordance with the PrivacyLaw,s.15.04(1)(m),Stats. <br /> L Application Information-Please Print All Information J0 A)Al" Jk lel <br /> Property Owner's Name Parcel# 07 e>c6 v?,39 <br /> / <br /> Property Owner's Mailing Address v -/ Property Loca ion Q <br /> 19 r 4 m Z-/� �P�/ Govt Lot q �/ <br /> City,State Zip�C[oddee Phone Number y, /., Section a <br /> (circle one) <br /> H.Type of Building(check all that apply) Lot# / <br /> T _N, R_1,7 Eor� <br /> X-I or 2 Family Dwelling-Number of Bedrooms 2 Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> 11 City of <br /> ❑State Owned-Describe Use CSM Number ElVillage of <br /> V!lO21/ ownof <br /> III.Type of Permit: (Check only one box on line A. Complete line B if appli ble) <br /> A. ❑New S <br /> ystem *eplacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <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 /> ,IyyV..'''T a of POWTS S em/Com ouenVDevice: Check all that s 1 <br /> 0-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 /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(st) Dispersal Area Proposed(sf) Sys[em Elevation <br /> SO 7 1 6y3 ds o 96, s <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units a o d v <br /> New Tanks Existing Tanks o U C Y y is <br /> aU q h w0 a <br /> Septic or ffakb g-Tank pp e. /600 <br /> Dosing Chamber 0 b 00 <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plmnb s�'Sign MP/1vIPRS Number Business Phone Number <br /> WADE RUFSHOLM 227691 715-349-7286 <br /> (((///1111// <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 <br /> VIII.Conn /De artment Use Only <br /> Approved ❑Disapproved Permit Fee Date Issued Issuing Agent Sign re <br /> ❑ Owner Given Reason for Denial � �' ' V ' �" <br /> OL Conditions of ApprovaVB•oasons for Disapproval <br /> AUG <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 la x I I me es in siva <br /> to <br /> _- --- - - 5 <br /> 0 <br /> NE77 <br /> 2aN/Hp UNT� <br />