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$rr r Safety and Buildings Division (J <br /> ; 1 <br /> 1400 E Washington Ave SanitaryPe�r9mitNumber(to be filled in by Co.) <br /> 1` SPS P.O. Box 7162 �DC�7 <br /> 7 _ <br /> \,� w fel' Madison,WI 53707-7162 <br /> �°xFssli nay J 1C� <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this fort to the appropriate governmental unit C ovw./V R ieNr`ew <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 m accordance with the Privacy Law,s.15.04(1)(m),Stats. <br /> I. Application Information—Please Print All Information <br /> Property Owner's NameParcel# p 7 O fol 07 Ve /j P2 3 5- <br /> iJ r .E� 7 06c7 <br /> Property Owner's Mailing Address Property Location <br /> /s©d Govt.Lot <br /> City,State Zip Code Phone Number /4, /., Section,;23 <br /> 00✓t?(' /()s .J:5-3UY circle one <br /> Il.Type of Building(check all that apply) Lot# T �N; R �� E o <br /> �(tor 2 Family Dwelling—Number of Bedrooms '�`- / I Subdivision Name // / �/` // <br /> -1 Block# L; 112!t/ TD 1/1 1(1 <br /> ❑Public/Commercial—Describe Use ❑City of <br /> ❑State Owned—Describe Use CSM Number ❑ Village of <br /> *Town of <br /> III.Type of Permit: (Check only one boa on line A. Complete line B if applicable) <br /> A. El New System ❑Replacement ment 5Ystem Treatment/Holding Tank Replacement Only Other Modification to Existing System(axPlan) <br /> B. ❑Permit Renewal ❑Permit Revision ❑ Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner -In3)% —/a <br /> / -7 <br /> IV.Type of POWTS System/Component/Device: Check all that apply) (Q c <br /> $-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 /> 300 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o e g <br /> New Tanks Existing Tanks c u y <br /> n.U on W <br /> Septic or Holding-leek ODo DDv o rW s e�L� <br /> Dosing Chamber <br /> VII.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 /> WADE RUFSHOLM f 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 ❑ Disapproved <br /> Permit Fee 00 Date Issued Issuing Agent Sign re <br /> ❑ Owner Given Reason for Denial $ J 75 O r/(a <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> R., <br /> ECEIVEnnAttach to complete plans for the system and submit to the County only on paper not less than 8ehrs <br /> 9.U Zulu ILJJ <br /> SURNMcolljNTY <br /> .e ONIW G <br />