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}t,pP✓•aYs1EYr4 County <br /> g1 oF'l� Safety and Buildings Division <br /> t ` S 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> p P.O. Box 7162 <br /> S <br /> 'a Madison,WI 53707-7162 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 3831](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 information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s. 15.04(1 m),Slats. / <br /> I. Application Information—Please Print All Information , /7 p?5 � L c)(-41 j R <br /> Property Owner's Name Parcel# S— <br /> J AIJ HA-r 5 f- 0.5- ov 6 0/ O r,>® <br /> Property Owner's Mailing Address 7% 4t Property Location,p L <br /> t ,) / a2 576 V Govt.Lot C <br /> City,Stale Zip Cude j Phone Number 'A, /., Section 3�5 <br /> ar�S L® Yom I seircle one <br /> II.Type of Building(check all that apply) Lot# T__ [ZN; R /5 E orCW <br /> 4 or 2 Family Dwelling—Number of Bedrooms z;2 J Subdivision Name <br /> , Block# <br /> ElPublic/Commercial—Describe Use <br /> ❑City of �- <br /> ❑State Owned—Describe Use CSM Number El village of <br /> XTown of <br /> III.Type of Permit: (Check only one box online A. Complete line B if applicable) <br /> A, ❑New System .°Replacement System Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of PlumberE❑Permit Transfer to New List Previous Permit Number and Due 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 ❑9ther Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Desi Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(st) Dispersal Area Proposed(sf) System Elevation <br /> 7�� <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units <br /> New Tanks Existing Tanks '� o �; Z a `� <br /> U in y rn f. V W <br /> Sapldor Holding Tank ODD ��� a f'L)C7 rLjc� G Cj <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) Plum is Signature /' MPIMPRS Number Business Phone Number <br /> WADE RUFSHOLM '. Jill <br /> / /�' 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) �i�' ///444"' <br /> PO BOX 514,SIREN,WI 54872 <br /> VIII.County/De artment Use Only <br /> Permit Fee Date Issued Issuing Agent Signal re <br /> Approved ❑ Disapproved $ pp <br /> ❑ Owner Given Reason for Denial 37,5� <br /> IX.Conditions of Approval/Reasons for Disapproval �f <br /> 14w 1B1&4,e V e 71 AV�il i Ej 1 Uc,��11 v E <br /> FnJ <br /> APO <br /> Attach to complete plans for the system and submit to the County only on paper not less titan a IR x 11 f hes Esi <br /> L'. <br /> - - - BUR=F-Tr COUNTY <br /> -ONING <br />