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`�6r+atusvTo County <br /> Safety and Buildings Division e <br /> -� $ 'M' 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> P P.O. Box 7162 Q r/p� <br /> °o Si/r Madison,WI 53707-7162 -533 /(�a <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 38321(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 / rte` <br /> purposes in accordance with the Privac Law,s.15.04(1 m,Stats. 17-5- <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel#O 7 O/ax .2 C1,01-If-lo? <br /> Borg 9-- ,J 3 /S .527 07 G� <br /> Property OwnWs Mailing Address <br /> � Property Location <br /> 9710 Y/ ae- /'i)&) Govt Lot <br /> City,State Zip Code Phones Number y4, /., Section <br /> /�� 16,�r3o 3 (�3 �p-7�8�t� circle one) <br /> T �N, R Eo>0 <br /> II.Type of Ba2ding(check all that apply) Lot# <br /> ;XJ or 2 Family Dwelling-Number of Bedrooms z;g t/7,7 4-t/,y <br /> Subdivision Name- <br /> Block <br /> ameBlockk# -re-P_,+ ane_ / x <br /> ❑Public/Commercial-Describe Use ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of -r-- �L <br /> `f�Town of \./.*C k_S0,J <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 /> B. El Permit Renewal El Permit Revision <br /> ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and�Djued <br /> Before Expiration Owner Is I <br /> IV.Type of POWTS S stem/Com onent/Device: Check all that apply) <br /> on-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(gpdst) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units w o o v <br /> New Tanks Existing Tanks w e ? y s <br /> a U rn y vl w(7 0. <br /> Septic or FIeW09Tank <br /> D /ado arev eSCv <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 Signaturc, 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 06 Date Issued Issuing Agent Signature <br /> 11 �V., <br /> Owner Given Reason for Denial 3 7S• � 7' Ca- ��? <br /> DL Conditions of ApprovaVRoasons for Disapproval <br /> TO9i <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8112 es <br /> ZONING <br />