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{ c , , ,,,,,r County
<br /> Safety and Buildings Division ,tjt/P�y)z•
<br /> e4 . 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.)
<br /> p ''•' Madison,WI 53707-7162
<br /> 514,"\1-Qa -LU-? 46 510
<br /> ,'' CST-,92 -7'
<br /> State Transaction Number
<br /> Sanitary Perrriit Application
<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 Servies. Personal information you provide may be used for secondary j.95y
<br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. n Y
<br /> I. Application Information-Please Print All Information /t) AI- D t*) 5' r`'
<br /> Property Owner's Name Parcel#(' 7 p /S' 0,2 7 « 3 4/
<br /> ]'o 711 C /e,e)•NSoo,J 5 i5" y7 027ovv
<br /> Property Owner's Mailing Address Property Location
<br /> 4 'X .5 8V Govt.Lot
<br /> City,State Zip Code
<br /> 7 Phone Number 1/4, A, Section 3 y
<br /> Si e_i,3 t:Ai y /d - 3/9 .3/D 7,9 5' (circle one
<br /> II.Type of Building(check all that apply) Lot# T 3 N; R /�i E o
<br /> 11-or 2 Family Dwelling-Number of Bedrooms / 6 Subdivision Name 41 o€iNc/ 8 G,4
<br /> Block# ACC_ 55(. ,^f
<br /> P'%f 7`.a.?
<br /> ❑Public/Commercial-Describe Use
<br /> ❑City of
<br /> ❑State Owned-Describe Use )
<br /> CSM Number ❑ Village of
<br /> own of J47 .c /'iG,/�
<br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable)
<br /> A' I ❑New System System ❑ Treatment/HoldingTank Replacement Only ❑ Other Modification to ExistingSystem(explain)
<br /> Y *Replacement Y P Y ( P )
<br /> i
<br /> i
<br /> B. ❑Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued
<br /> i ! Before Expiration Owner
<br /> 1 IV.Type of POWTS System/Component/Device: (Check all that apply)
<br /> Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil
<br /> ❑ Holding Tank 0 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(sf) Dispersal Area Proposed(st) System Elevation
<br /> q5 6 , —26"7 3 d 3-e) 76
<br /> VI.Tank Info Capacity in Total #of Manufacturer
<br /> Gallons Gallons Units a, o :3 U
<br /> aI o U " `" N
<br /> New Tanks Existing Tanks ,-, c 0.) 8 a 2 2
<br /> cC U v) ,,, v1 w 0 ri
<br /> Septic or Bolt.g-T-ia;k /6 o e / e / r
<br /> e i -,,,r-
<br /> Dosing Chamber / D �-� eU()
<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 Signature MP/MPRS Number Business Phone Number
<br /> WADE RUFSHOLM �\r227691 715-349-7286
<br /> Plumber's Address(Street,City,State,Zip Code) (�/ /-x--e'-,--,,4----
<br /> PO BOX 514,SIREN,WI 54872
<br /> VIII.County/Department Use Only
<br /> Approved I
<br /> ❑ Disapproved Permit Fee CO Date Issued Is ng��Age Signatur
<br /> ❑Owner Given Reason for Denial $ 1 P5 6f 2.i?2 C/� �""r'
<br /> IX.Conditions of Approval •ason• for Disapproval ilr (O( 4' '-‘,12c
<br /> eek all s.e. . l CC� COMEn
<br /> ni ee4- weu •
<br /> s • - 40 nets, k�t,
<br /> JUN 0 1 2022 t U
<br /> JAttach to complete plans for the system and submit to the County only on paper not less than 8 1/ c 11 :hes insize
<br /> 'Mundt county
<br /> SBD-6398(R. 11/11) Land Services Department
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