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YAIiTO" <br /> county <br /> Safety and Buildings Division <br /> $ K� 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> P �. P.O. Box 7162 n <br /> S ��� Madison,WI 53707-7162 �� <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 fors 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 it <br /> purposes in accordance with the Privacy Law,s. 15.04 1 m,Stats. <br /> 1. Application Information—Please Print All Information <br /> Property P er's Name Parcel#Q <br /> oa 006) 0 '/000 <br /> Property Owner's Mailing Addressr Property Location <br /> oF0 ! �� (�r kIUt?r R Go Lot <br /> City,State Zip Code Phone Number w � 3� <br /> (3 ,t�� // f/`ls� / / Y.,S %y Section <br /> 3 r"/ fsb U/` L rJ 5-7 6 7 o 7f-S ;T 07 3�6 (circle one <br /> II.Type of Building eck all that apply) Lot# T 7 N; R 1�_E o(W) <br /> 7*or 2 Family Dwelling—Number of Bedrooms Subdivision Name <br /> �-- Block# <br /> ❑Public/Commercial—Describe Use <br /> Ll city of <br /> �- <br /> CSM <br /> ❑State Owned—Describe Use Number El Village of <br /> / <br /> XTown of <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. New System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> ) <br /> B. El Permit Renewal El Permit Revision El Change of Plumber 11 Permit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> 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 ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow <br /> /(gpd) Design Soil Application Rate(gpdsf) Dispersal <br /> Area Required(s0 Dispersal Area Proposed(so System Elevation <br /> rs <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units <br /> New Tanks Existing Tanks ^-� eo a; y <br /> M <br /> Sepfic or in Tank �D D�© ! f�/ G, <br /> Dosing Chamber <br /> VII.Responsibility Statement- 1,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 /> i <br /> VIII.County/Department Use Only <br /> Approved [I Disapproved Permit`7Fee � Date Issued issuing Age Signature <br /> ❑ Owner Given Reason for Denial $ / �' O <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> CST-I 49 Attach to complete plans for the system and submit to the County only on paper not less than 8 112 x 11 inches in size <br />