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t¢ $'OS <br /> ofs—ieg 7M Cnntl <br /> �� �� Safety and Buildings Division 4,/'�e v� <br /> 1a 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> S <br /> P.O. Box 7162 ���0 <br /> pS <br /> ,,�',/ Madison,WI 53707-7162 <br /> S <br /> "�Y3SNlt+N w <br /> Sanitary Permit AppllCat1011 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 <br /> purposes in accordance with the Privacy Law,s. 15.04(L)(m,Stats. <br /> L Application Information—Please Print All Information <br /> PropeOwner's Name Parcel# -7 <br /> Z 0er A esse�r .S s- a ozoa� <br /> Property Owner's Mailing Address ,l ��` Properly Location <br /> tS a Ate'/ �✓ Govt.Lot <br /> City,State Zip Code Phone Number <br /> /., /., Section <br /> y r circle on <br /> H.Type of Building(check all that apply) Lot# T�N; E r W <br /> ; trvr 2 Family Dwelling—Number of Bedrooms a? -3 P Subdivision Namee <br /> Block# <br /> ❑Public/Commercial—Describe Use <br /> ❑City of <br /> ❑State Owned—Describe Use <br /> CSM Number ❑ Village of <br /> �— "�(Townof <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. 11 New SystemiILleplacement System Treatment/[ Tank Replacement Only Other Modification to Existing System(explain) <br /> I <br /> B. El Permit Renewal El Permit Revision El Change of Plumber <br /> ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS S stem/Com onent/Device: Check all that apply) <br /> X-11on-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 Rale(gpdst) Dispersal Arca Required(s0 Dispersal Area Proposed(sf) System Elevation <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> New Tanks <br /> Gallons Gallons Units <br /> Existing Tanks U , <br /> a V in rn � W C7 ii, <br /> Septic or Haldiagamir- �7 <"""� "� L— <br /> Dosing Chamber ~J <br /> VII.Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumbfr's Signature MP"1 Number Business Phone Number <br /> WADE RUFSHOLM 4XG/' ffi 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 El Disapproved Permit Fee Date Issued Issuing Agent Signature/ <br /> ❑Owner Given Reason for Denial $3)6�'00 <br /> ? <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach to colup ete pla s for the system and submit to the Count}only on paper not less than 8 in ill inches in size <br />