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YownTa`F o` County�Al <br /> t r, Safety and Buildings Division , lwe-7'� <br /> 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> Be P r` P.O. Box 7162 <br /> Madison,WI 53707-7162 �d780 <br /> ��/r --I <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SYS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit G OUN f C UI tee.LV <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 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 <br /> Property Owner's Name <br /> Parcel# B 042 a7 96 J_-J aZ <br /> Property Owner's Mailing Address Property Location <br /> a / 0l;Ue r ,'t r A),, Govt.Lot -7 <br /> City,State Zip Code Phone Number , , �OS, <br /> /., Section <br /> J/ `5* Eone <br /> II. ype of Building(check all that apply) Lot T T� N; R E ow <br /> �7 Subdivision Name <br /> IZS.1 or 2 Fatuity Dwelling-Number of Bedrooms � B c�.�j t-- C� �/c >� gle� � <br /> /❑Public/Commercial-Describe Use J /l{. <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑ village of <br /> j' �40wn of J <br /> Ill.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. KNew System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑Permit Revision ❑ Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration IOwner <br /> IV.Type of POWTS System/Component/Device: Check all that apply) <br /> Non-Pressurized In-Ground El Pressurized In-Ground ❑At-Grade El Mound>24 in.of suitable soil El 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(gpdsl) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> SpCJ <br /> a I A Z i�YSd <br /> VI.Tank Info Capacity ihi Total #of Manufacturer <br /> Gallons Gallons Units v$ <br /> New Tanks Existing Tanks <br /> is w C7 W <br /> Septic or idoldrig-Taa,k <br /> 756) SQ G M <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) Plumb is Signature MP/MPRS Number Business Phone Number <br /> WADE RUFSHOLM /� y_. 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) �t <br /> PO BOX 514,SIREN,WI 54872 <br /> VIII.Coun /De artment Use Only <br /> Permit Fee G Date Issued issuing Agent Signature <br /> Approved ❑ Disapproved j p <br /> El Owner Given Reason for Denial $ J T 5- l -li D J <br /> IX.Conditions of ApprovaUReasons for Disapproval <br /> ^�✓� __---A ttech to complete plans for the system and submit to the County only on paper not less than 8 in x 11 inches in size <br />