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y��F.ioT.i((t4T� ('.OUII� <br /> ^ yr Safety and Buildings Division <br /> �} $ �i 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> `t ps ;y P.O. 2 <br /> Madison,WIl 5370 53707-7162 O �1'/�,L Q <br /> f��`Fssao`w &9 V �J <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(t)(m),Stats. <br /> L Application Information—Please Print All Information % 6 <br /> Property Owner's Ne Parcel# C"7 ©/ 3 7 / 7 33 <br /> 1 : r -3 C-3 O oesc> <br /> Property O is MailingAddress Property Location <br /> 61 L� Govt.Lot <br /> City,State Zip Code Phone Number 6J y, SyJ V., Section 3:-F <br /> (circle one) <br /> H.Type of Building(check all that apply) / Lot# <br /> � T N; R 1�E or� <br /> $1,or 2 Family Dwelling—Number of Bedrooms r Subdivision Name <br /> Block# <br /> ❑Public/Commercial—Describe Use ❑City of <br /> 1� <br /> ❑ CSM Number ❑ Village of <br /> State Owned—Describe Use w <br /> iP(Town of Z_�,.o <br /> IIL Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> ` - ❑New system ❑ Replacement System VTreatment/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 /> W.Type of POWTS System/Component/Device: Check all that apply) <br /> f'Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 inof 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(gpdst) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> d <br /> Gallons Gallons Units U d y <br /> New Tanks Existing Tanks c ,� 2 <br /> a, U CO .., rn <br /> Septic or ank /Moo <br /> Dosing -,� Ooa C3rli(J P—g�G[� <br /> 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 Sign a /1 MP/MPRS Number Business Phone Number <br /> WADE RUFSHOLM //� 227691 715-349-7286 <br /> "00 <br /> c <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 <br /> VIII.County/Department Use Only 1 <br /> Approved El Disapproved Permit Fee DQate Issued Issuing Agent Signature <br /> ❑ Owner Given Reason for Denial $ J 7S' o o I r oU �� <br /> DC.Conditions of Approval/Reasons for Disapproval ECEIVI) <br /> S� �a es r SEP 11 1016 <br /> Attach to complete plans for the system and submit to the County only on paper not less than a 12 x 11 is <br /> �a�rr ZONING couNrY <br />