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i A County <br /> Safety and Buildings Division <br /> r 0 201 W.Washington Ave., P.O. Boz 7162 Sanitary Permit Number(to be filled in by Co.) <br /> Sps ;� Madison,WI 53707-7162 <br /> s <br /> Sanitary Permit Application Slate Tra nation Number <br /> In acrordance with SPS 383?I(2),Wis.Adm.Code,submission of this form to the appropos a gm emmental unit 0`a 0 D- <br /> is required prior to obtaining a sanitary permit. Note:APYlicatinn loons for nateawneJ l'OWTS are submitted to Project Address(ddiferent than mailing address) <br /> the Department of Safety and Professional Stories. Personal information you provide may be used for secondary j� <br /> purposes in accordance with the Privacy law,s. IS 04 I ar,Stars, '7 - LSA <br /> I. A /�OV-..fApplication Information-Please Print All Information /ck <br /> Property Ow er's Name Parcel 9 "17 d 3 0l' 37 /5i ad <br /> B err Ca3� s Sas ooa o 3 <br /> Pmpmy Owner's Mailing Address Property Location <br /> 6oII6 asks . �ir�/e n�. GoviLm02 <br /> City,Stale Zip Codc Phone Number <br /> 0A/ )/S-1,28 (oirdI.o <br /> IT,Type of Building(check all that apply) Loth T3N, RE <br /> or 2 Family Dwelling-Number of Bedrooms 152 1?- Subdivision Namc <br /> _ 61ock9 <br /> 0 Public/Commer ad-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use <br /> CSM Number 0 Villageof <br /> ✓a I P/sa �Tpwnof T/ e <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. [�,Ialcw System O Replacement System O Treatmenpllolding Took Replacement Only O Other Mishmutiun to Existing System(explain) <br /> B. 0 Permit Renewal 0 Permit Revisiw ❑Change of Plumber 0 Pc.a Transfer m New List Previous Permit Number and Dale Issued <br /> Before Exportation Owner <br /> IV.Type of POWTS 5 stem/Com onenUDevite: Check all that a I <br /> ❑Non-Pressurized In-Ground ❑ Yressurived In-Gmund ❑AI-0mde 'KMmirm,24 in.of suitable it 0 Mound<24 imofsuitable soil <br /> O Holding Tank O Other Dispersal Component(explain) O Pretreatment Desice(eeplain) <br /> V.Dis ersalffreatment Area Information: <br /> IRsign Flow(gpd) Design Soil A plication Iiate(gpds0 Dispersal Area Required(so 1)ispio,W Area Pnop 7cd(sD Sysrem LIccut.a <br /> 3o e Sod 1 3a a 97,9 <br /> VI.Tank Info Capacity in 'rural a of Manufacturer _ <br /> GWlca Dollars Units d o <br /> New Tonka Exisuny'farrks `e N 3 `ted' `Vit <br /> iU - U a <br /> Septic or Irk <br /> on,inscmm6re _ sit <br /> VII.Responsibility Statement- I,(he undersigned,assume responsibility fur installation pt the P03YP5 shown,on Me arvchetl Olans. <br /> Plumber's Name(Print) Plumber's Signal MP)MPIiS Number Bu......Phone Number <br /> WADE RUFSHOLIA P I 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) (/C/ <br /> PO BOX 514,SIREN,W 1548'/2 <br /> 11111111.C... /De artment Use Orl <br /> Approved ❑Disapproved $ermit Pee �N ssuin Dace Is eJ� Io Signazurc <br /> 0 Owner Given Rename for Denial /1 <br /> IX.Conditions of Approval/Reasons for Disapproval7 <br /> Amro to complete plan,ror the—rem,m submit m me C...by only on nave.nm It.to..B w r u I-oh-in she <br />