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ogeAaTMayT county <br /> / <br /> Safety and Buildings Division y�,J <br /> 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> S p$ <br /> P.O. Box 7162 <br /> Madison,WI 53707-7162 <br /> anhO�stlWa��' / II�r 7�LJ <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 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. yi!/G <br /> L Application Information-Please Print All Information !1 /`Arm' <br /> Property Owner's Name Parcel# 0 7 04a a SICK S,2-7 <br /> ,go L /�/' �Z 5-05- . Z p 2�Ocs0 <br /> Property Owner's Mailing Address property Locations`l <br /> y3a S .s 4/ S Govt Lot a <br /> City,State Zip Code Phone N� be <br /> umber y, v, Section o2 3 <br /> (circle on <br /> J! re.n) ZA,.y— /✓ 77,,? 3!// -/7 T 7 N, R -S-_E0 <br /> II.Type of Building(check all that apply) Lot# <br /> or 2 Family Dwelling-Number of Bedrooms Subdivision Nama <br /> PI — <br /> Block# <br /> ❑Public/Commercial-Describe Use ❑ City of <br /> CSM Number Village of <br /> ❑State Owned-Describe Use '— ❑ <br /> ATown of <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A- ),,New System ❑Replacement 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 /> 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 /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application RaWZpdst) Dispersal Area Required(st) Dispersal Area Proposed(sf) System Elevation <br /> 3-IP4 , -� y�9 vs y�� <br /> VL Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units <br /> New Tanks Existing Talcs v <br /> Septic orHeklm& :adr /69Cif) r-W�sc� <br /> Dosing Chamber <br /> VIL 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 MP1WRS Number Business Phone Number <br /> WADE RUFSHOLM 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 11 Disapproved Permit Fee Date issued Issuing Agent Signature <br /> ❑Owner Given Reason for Denial ✓� 1 a -�� <br /> Df.Conditions of Approval/Reasons for Disapproval <br /> Attach to complete plans for the system and submit to the County oily on paper not less than 8 in x 11 inches in size <br />