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County /7 <br /> Safety and Buildings Division ,o t,,,-A)el/ <br /> 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> • \ P,..., Madison,WI 53707-7162 <br /> Saki—on— 15q li.,14(ce4/7 <br /> , . <br /> Sanitary 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 Servies. Personal information you provide may be used for secondary 39,.4 3 o <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. <br /> I. Application Information-Please Print All Information • '--C)r-C-O.^A A; ki <br /> Property Owner's Name i , Parcel# e) 7 036. a ye /7 3.6 <br /> 'Tom Keetim" , , <br /> 15 -5 77 03Y/06 <br /> Property Owner's Mailing Address Property Location <br /> /3 gio G e.0 e_.VA Wily Govt.Lot <br /> City,State Zip Code Phone Number 1/4, 1/4, Section 3 C <br /> Via Viliky /1),,I .37C7;?1/ v 0 N; R /7(circle one <br /> T <br /> Eo _....j <br /> It Type of Bing(check all that apply) Lot# <br /> a C -a? -7-)S?-177 'Y 4-34)or 2 Family Dwelling-Number of Bedrooms 7 Subdivision Name <br /> Block# -1"/• - t0 <br /> /ft)e.5, 0 Public/Commercial-Describe Use <br /> t.. 0 City of <br /> — <br /> _.-- <br /> 0 State Owned-Describe Use CSM Number 0 Village of I 4 <br /> — AT4own of aiii i 0 it) <br /> III,Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. i n <br /> i i_i New System Replacement System 0 Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> B. I 0 Permit Renewal 0 Permit Revision 0 Change of Plumber 0 Permit Transfer to New List Previous Permit Number and Date Issued <br /> 1 Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> 0 Non-Pressurized in-Ground 0 Pressurized In-Ground 0 At-Grade 0 Mound>24 in.of suitable soil 0 Mound<24 in.of suitable soil <br /> Aiolding Tank n Other Dispersal Component(explain) 0 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(sf) System Elevation <br /> 1 .r---- <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> 4.) <br /> Gallons Gallons Units a" o <br /> fit ct c-) 2 <br /> New Tanks Existing Tanks 48 = 0 2 T3 .' g -2 <br /> ,t (5 .g,. r.: 3 5. <br /> i <br /> 61491+C or Holding Tank I el <br /> ip- tA2 0 4,7006 / t fo,e6 6,-..1" --/-- <br /> Dosing 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 Signature MP/MPRS Number Business Phone Number <br /> WADE RUFSHOLM 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 /> Permit Fee 0 Date Issued I 'ng Age Signature //// <br /> X Approved 0 Disapproved <br /> I 0 Owner Given Reason for Denial 375 <br /> 7 /(3/2d • . ,-, -.r- <br /> ,fe7C- EOVIE ')) <br /> IX.Conditions of Approval easo s for Disapproval <br /> tWee1 4d IC 41161)6 7 <br /> % <br /> ce.,„,„t r„..„ ,5 b;ile l'fs )Y JUL 1 1 a122 j <br /> Vat,4-ir74 <br /> Attach to complete p ens for the system a d submit to the County only on paper not less than 8 1/4 x 11 inches in t brnett County <br /> Land Service*Department <br /> SBD-6398(R. 11/11) <br />