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county <br /> Safety and Buildings Division /- <br /> �� a 1s 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> 11; S P IA P.O.Box 7162 SA - 1']-09 <br /> Iwo ' Madison,WI 53707 7162 S Q Il S <br /> wvA�co / �1 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 38321(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 imbrmatiou you provide may be used for secondary 7a 7 C / <br /> purposes in accordance with the Privacy Law,s.I5-KIXmj Stets. <br /> L Application Information-Please Print All Information <br /> Property Owner's Name Parcel# p p o?{ d <br /> c `J <br /> Ql5 .e, Bc y Oo7000C� <br /> Property O er's Mailing Address Property motion 10C <br /> N ` S Govt.Lot-F--- <br /> City s� Zip Code Phone Number y, 1/1, Section <br /> � J ) '/ (circle one <br /> /�'�U �u D�`/� �o - OS- o2bJ� I.7�N, R _E <br /> II.Type of Building(check all that apply) r7 Lot# <br /> Subdivision Name <br /> /KI or 2 Family Dwelling-Number of Bedrooms <br /> Block# <br /> ❑Public/Comnercial-Describe Use ❑City of <br /> CSM Number ❑Village of <br /> ❑State Owned-Describe Use <br /> �3'own of <br /> III.Type of Permit: (Check only one boa on Tine A. Complete line B if applicable) <br /> A- ❑New System �ceplacement system ❑Treatment/Holding Tank Replacement Only El other Modification to Existing System(explain) <br /> t List Previous Permit Number and Dade Issued <br /> B• ❑Permit Renewal ❑ Permit Revision ❑Change of Plumber ❑Permit Transfer to New <br /> Before Expiration Owner <br /> IV.T of POWTS S em/Com onent/Device: Check all that a <br /> {'.Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑Mound 2:2 in.of suitable soil ❑Mound<24 is of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Preheatm`cnt Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(so Dispersal Area Proposed(sf) System Elevation <br /> / 7 y <br /> VL Tank Info Capacity in Total #of Maoufadiuer <br /> c <br /> Gallons Gallons Units °��' <br /> New Tanks E�dstmg Tani= o S 2 P a <br /> Septic orHalk �dOLI -- �dOd <br /> Dosing Chamber Q �- <br /> VIL Responsibility Statement-1,the undersigned,assume responsibility for installation of the POWLS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MPlMPRS Number Business Phone Number <br /> WADE RUFSHOLM �l �- 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 <br /> V11L Court /De artment Use Out <br /> Permit Fee Date Issued r Sigoatue <br /> �(pproved ❑Disapproved �� 5 �a,I_ �ij J f <br /> ❑Owner Given Reason for Denial "I / <br /> IS.Conditions of Approv Viteasons for Disapproval <br /> Attach to complete plans for the system and submit to the County only 011 paper not less than a'A z 11 i nches na size <br />