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bas¢,4ANT1 ,Ot County <br /> Safety and Buildings Division ,�E//�C <br /> I ` �S 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> �a�P S II P.O. Box 7162 x;2`X"�/ ✓/ <br /> _ Madison,Wf 53707-7162 <br /> w�•'eaa�Ab,. � �� T <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 26 <br /> is required prior to obtaining a si nitaq per it, Nott: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. S 6/y I�, <br /> I. Application Information—Please Print All Information <br /> Property Owner's Name / / Parcel# <br /> /.YI 4 /7�Alf� e- p3 c9oc) 01,;200o <br /> Property Owner's Mailing Address Property Location L <br /> 3 �3 L! /� 6,,1 c.)oJ L I\ /\� Govt.Lot <br /> City,State Zip Code Phone Number (� , <br /> � S /., h1 UJ /,, Section -.2 <br /> G✓��� S� d w� SYS '0c _ <br /> S;' oneL <br /> 11.Type of Building(chec that apply) Lot# T 3 N; R j 2S E o W <br /> Tor 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> �. Block# I❑ <br /> ElPublic/Commercial-(Describe Use City of ---� <br /> El State Owned-Describe Use ,�, <br /> CSM Nur El village of <br /> 126own of <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A• ❑New System �(Re lacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> ) <br /> B. 11 Permit Renewal ❑ PerihriC,Revision ❑ Change of Plumber ❑PermitTrtmsfertoNew <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS S stem/Com onent(Device: Check all that apply) <br /> ❑Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑At-Grade ❑ Mound>24 in.of suitable soil Nlound<24 in.of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow©) Design Spil Application Rate(gpdst) Dispersal Area Required(sf) Dispersal �oposed(sfl System Elevation <br /> S 7e /7�-_^� 7 <br /> V1.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units <br /> New Tanks Existing Tanks <br /> septic or lold� l p G <br /> U r �p <br /> Dosing Chamber e c <br /> VII.Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWIrS shown on the attached plans. <br /> Plumber's Name(Print) Plumber ature MPIMPRS 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.Court !De artment Use Only <br /> Approved Disapproved <br /> Permit Fee Date Issued issuing Agent Sign e <br /> ❑ �fl I li $ � � A <br /> ❑Owner Given Reason for DeiLl <br /> IX.Conditions of Approval/Reasons for Disapproval �n �i► <br /> � U Ifs <br /> ItAr_-�15val <br /> p3 216 <br /> Attach to complete plans for the system and submit to the County only on paper not less than a 1 x t 111tilacheSi in Sl <br />