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County <br /> Safety and Buildings Division Nr'/i <br /> 1400 E Washington Ave Sanitary ( / yCo.) <br /> Sari Permit Number to be filled in b Co. <br /> P.O.Box7162 " -21`2fo� C0y0�p01 <br /> Madison,WI 53707-7162 <br /> i <br /> Sanity 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 Services. Personal information you provide may be used for secondary 32$2.3 <br /> purposes in accordance with the Privacy Law,s.15.0 1)m,Stats. <br /> 7. Application Information—]Please Print All Information <br /> I Prooerty Owner's Nam/e� Parcel# O <br /> �f- <br /> A- .v 14 kes�e e- � o Doo a!//00 <br /> l Property Owner soMailing Address Property Location <br /> SCJe—(-9.f C k /\Q I d Govt.Lot <br /> City,State Zip Code Phone Number SE <, <br /> / !` /a, Section <br /> G r/�J�s O y W J y�/ WO —7T 77 (circle on <br /> ! 11 Type of Building(check A that apply) L. Lot# T _N, R _E o <br /> { or 2 Family Dwelling—Number of Bedrooms / Subdivision Name <br /> j Block# <br /> j U Public/Commercial—Describe Use ❑City of <br /> i <br /> j ❑State Owned—Describe Use CSM Number El village of <br /> iVo�3 per/ `7' X'ownof <br /> DR. !ype of Permit: (Check only one box on line A. Complete line 13 if applicable) <br /> A. ❑New System VkRepiacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> i <br /> T• '_i Permit Renewal ElPermit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> Type of IaOWTS System/Component/Device: (Check all that app1 <br /> FATon-Pressurized In-Ground ❑ Pressurized In-Ground El At-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> j ? Hoiding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dis ersa➢/Treatunent Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdso Dispersal Area Required(so Dispersal Area Proposed(so System Elevation <br /> 77 <br /> 1,7.Tank lnfo Capacity in Total #of Manufacturer <br /> Gallons Gallons Units n ° o <br /> New Tanks Existing Tanks o2 L <br /> I <br /> Septic or 7ieldin�k p`F•- <br /> + Dosing Chamber CiCJ <br /> VIII.Responsibility Statement- 1,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 /> SHADE RUFSHOLM � 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX.514,SIREN,4VI 54872 <br /> I <br /> i V1Ci[Ti.Count /Il➢e artment Use Only <br /> Permit Fee Date Issued I Ventgnature <br /> 0 <br /> Approved El Disapproved <br /> I <br /> i ❑Owner Given Reason for Denial <br /> RX.Conditions of ApprovaVReasons for Disapproval C <br /> A <br /> � ECE0V IF <br /> iL <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 to x n in i 2021 <br /> S3 6398(R0313) LU <br /> matt CoUnty <br /> Land Services Department <br />