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�heAne,feyT County <br /> Safety and Buildings Division A4 ^A) Z <br /> 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> P.O. Box 7162 g-7gq <br /> Madison,WI 53707-7162 I <br /> y`e3Slo`nVg�p <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. <br /> I. Application Information-Please Print All Information <br /> Pro Owner's Name Parcel# G 7 c D n 7 <br /> ei t e-, A- r/i- 05- C)o00 <br /> Property Owner's Mailing Address Property Location <br /> ,�ZA L G )• 1l-e.. Govt.Lot L3 <br /> City,State Zip Code Phone <br /> jb Number 7 p y, /y Section <br /> gJ �v !� bT Z (� N; R _ Eo� <br /> H.Type of Building(check all that apply) Lot# <br /> ❑I or 2 Family Dwelling-Number of Bedrooms e-3 C;11 Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> CSM Number ❑Village of <br /> 11 State Owned-Describe Use <br /> V1 a.7ff -0-Town of <br /> :-50/tI <br /> III.Type of Permit: (Check only one bog on line A. Complete line B if applicable) <br /> A, ❑New System ❑Replacement System 7-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 )d qAZ:;, 4—�Q_00 <br /> IV.Type of POWTS S stem/Com onent/Device: Check all that a 1 <br /> ❑Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑Mound>24 in_of suitable soil ❑Mound<24 in.of suitable soi <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(so Dispersal Area Proposed(so System Elevation <br /> VI.Tank Info Capacity in Total #of Manufacturer o <br /> Gallons Gallons Units <br /> � B � <br /> New Tanks Existing Tanks y o a Y a A <br /> n.U on y w C7 W <br /> Septics g ark <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 MP/MPRS Number Business Phone Number <br /> WADE RUFSHOLM $/ / ZL 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) R�� <br /> PO BOX 514,SIREN,WI 54872 <br /> VIII.Cour /De artment Use Only <br /> Approved ❑Disapproved Permit Fee Date Issued Issuing Agent Signablit) <br /> 375.O ❑ Owner Given Reason for Denial $ ,37S- <br /> OL <br /> L Condfions of Approval/Reasons for Disapproval <br /> Attach to complete plans for the system and submitto the County only on paper not less than 8 in z 11 inches is size <br />