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`,'0.,$.N 40.." County <br /> • <br /> Safety and Buildings Division �BN CA)`e-/ <br /> p S 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> p Madison,WI 53707-7162NI-23 <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 - - <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. <br /> I. Application Information-Please Print All Information ,:zt <br /> Property Owner's Name r ` 1# 0 7 DO 6 a.�B/7 d 5-,7 <br /> edtt)A-rcJ �To5ei9% in/N/57oe5 .Z'ivC - �, ---_ _ _ 4-0�., ooa o//Oo0 <br /> Property Owner's Mailing Adddress .i.n Sid I Ie Property Location <br /> J 3$7/ 7-4//A N d1 e r PI Govt.Lot <br /> City,State Zip Code Phone Number ,SC 4A, ^/LJ 'A, Section /5 <br /> ,5/f e t 17 .S''/F7 Z 7'5-- q,' '-,CV3 38 circle one <br /> T N; R E o W <br /> II.Type of Building(check all that apply) Lot# <br /> I1 or 2 Family Dwelling-Number of Bedrooms 3 — Subdivision Name <br /> ..---- <br /> Block# <br /> — <br /> 0 Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use <br /> CSM Number ❑ Village of , <br /> )4 Town of b A--/o/ -/.s <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' 0 New System 7.Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal 0 Permit Revision ❑ Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> XNon-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(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(st) Dispersal Area Proposed(st) System Elevation <br /> yro . 7 ‘y.; d.o q7, <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units c <br /> U °' ,.. y <br /> New Tanks Existing Tanks y 2 8 .2 <br /> k U in y ti iz. C7 is. <br /> Septic or I3aldix&Tank fV 00 — 1M2. / -t ei 17Lprf-7L r ?(-- <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 /> ' 'Approved ❑Disapproved Permit Fee vo Date Issued Issu ng gent,Siy,. re <br /> 12 <br /> ❑Owner Given Reason for Denial $L)P-5 6!r 1 P't9-3 i sOr <br /> IX.Conditions of Approval/Reasons for Disapproval It <br /> C . V <br /> r'7eek all CO" s�►ie c <br /> Vc i1 Scti 1 �►'1e ® � SQ S 36"3. 2 6 <br /> ,ins ;o n 4 s cii be: „043.11 -fr be J U N 0 9 2023 J <br /> P� <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x]1 inches m s'$urnett County <br /> Land Services Department <br /> 11-I2.5 ci R,k 4-J 1pLAS5 <br /> SBD-6398(R. I1/I 1) <br />