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prI sn"!o County <br /> Safety and Buildings Division Burne6 <br /> 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by C.-) <br /> p S1 Madison,WI 53707-7162 <br /> S(,&S!`� <br /> Sanitary Permit Application rote Tm a ion Numb r UJ <br /> In acenManee win SPS 383 21(2),Wis,Adm.Cash,submission of Nis form to the appre ate gnvemmenW too I r. <br /> erequired prior to obtaining a sanitary permit. Note:Appliwtim forms far studit.ed POWTS are subm tted to Project Address(if different than mailing address) V <br /> the Dxparanent of Safety and Professional Servies. Personal information you provide may he used for secondary <br /> parf,wes in accordance with the Pn,a,,low,s. 15.04(1 m),Stens. 6256 Pike Bend Rd. <br /> 1. Application Information-Please Print All lnformatfon <br /> Property Owner's Name r Parcel N <br /> Jerome Ellingson , 07-018-2-39-16-26401-000.015000 <br /> Propery Owner's Mailing Address f 1 Pmprny location <br /> 904 235"St <br /> Govt.For <br /> City,Stals zip Corin Phone Number NE v.,SE v., section 26 <br /> Osceola WI 54020 �,s- ass-aD49 ircleine) <br /> 11.Type of Building(check all that apply) Lot b T39 N; R166u <br /> ® I or 2 Family Dwelling-Number of Bedrooms 3 No Subdivision Name <br /> Black <br /> ❑Publie/Commereial-Describe Use <br /> ❑Sate Owned-Describe Ilse NA 11 City of <br /> CSM Number ❑ Village of <br /> Na ®Town of osn meed," <br /> Ill.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A_ LEI News ystem It Replacement System ❑Treammnol].]ding I ank Rep]..t Only ❑Fiber Modification to Existing System(explain) <br /> B. El Permit Renewal ❑ Permit Revision ❑CM1angeof Plumber ❑permit'1'ransfn t.New Ltn Pte°nous Permit Numher and Dene Issued <br /> Before Expiration (Tuner <br /> IV.T eof POWTSS stem/Com onent/Device: Check all that apply) <br /> O Non-PressurizedIn-Ground ❑ Pressudaed In-Ground ❑AI-0rale ❑Moand>_24 in of suitable soil ❑Mound<24 a.of suitable soil <br /> ® Ilolding'raM ❑ONer Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dis ersaVrreatment Area Information: <br /> Design Flow(gpd) Dasign Soil Application Rate(gp ist) Dispersal Arca Ra umal(sf Dispersal Ama Proposed(s0 System Elevation <br /> 450 Na No No Na <br /> VI.Tank Info Capacity in Tara) pof Manufacturer <br /> Gallons Gallons llniw a at <br /> y w <br /> New Tanks Existing Tanks <br /> au 2 gU a <br /> seem or B.Iding Tan 2000 2000Wieser Concrete WLP g <br /> nosing`bammotr 1250/750 <br /> VII.ResponsibilityStatement- [,the undersigned,assume responsibility for installafiom of the POMTS shown on the attached plans. <br /> Plumber's Name frinp umber's Signature MP/MPRS Number Business Phone Number <br /> Jerome Ellingson �a 3�O 715755-2049 <br /> Plomheds Address(Strew,city,Stmt,zip(We) 0 <br /> 904 2351°St.Osceola W 154020 <br /> VIII.Coon /De .rtment Use Only <br /> ❑Approved ❑Disapproved 1 mtit F'jcc� IA Date Issued Issmm cut Signmure <br /> ED <br /> (Tuner Given Rcasnn tm Denial <br /> VC Conditions of ApprovalfRersons for Disapproval D KEW <br /> E rnn <br /> JUL Ill 0 2013 D <br /> Amato to romplNe plans for 1M rawas mad submit b the County only so paper not len than g to a 11nom S SUR <br /> DlJrf e-rr couNTv <br /> ZONING <br />