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County <br /> Safely and Buildings Division C4 <br /> s 1400 E Washington Ave Sanitary Pe r/ml Number(to be filled in by Co.) <br /> P.O. Boz 7162 a/o 9yo <br /> 71 F S "� Madison,WI 53707-7162 <br /> Sanitary Permit Application State'Iransoubmn Number <br /> In accordance with SPS 38321(2),Wis.Adm.Code,submission of this form to the appropriate govcmincnml unit <br /> is required prior to obtaining a senitary permit Note:Application forms hu slate-owned POW l S me submitted to Project Address(ifditferent than mailing address) <br /> the Department of Safety end Professional Services. Personal information you provide may be urvd far secondary Sp:. <br /> P.M..in accordance with the Privacy,Late,s.15.10 I m,Stats. <br /> L Application Information-Please Print All Information <br /> Property Owner's Name Parcel q O <br /> �.O/'r <br /> Property Owner's Mailing Address p Property Location P / <br /> a}-7 5 f}N @ r /I rD Govt.Lot_ <br /> Cos.State <br /> // Zip Code Phone Number A) 1A, A.4-1 /., Section l� <br /> +(.b �r=r W.� 5.y✓G�3le one) <br /> "f 3tY N; R�Co� <br /> It.Type of Building(check all that apply) Lot <br /> Ida or 2 Family Dwelling-Number of Bedrooms -3 Subdivision Name <br /> Block% <br /> ❑PublidCommacial-Describe Use 11 City of <br /> CSM Number U Village of <br /> ❑State Owned-Describe Use ;o4o <br /> caro of �/}1✓/� S <br /> 111.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A [I New System �t R'lacemem S"wro U 1eatmeoUi holding Tank Replacement Only Other Modification to Existing System(explain) <br /> d Date Issued <br /> B. ❑Permit Renewed ❑ Permit Revision ❑Change of Plumber ❑Permit Trmrsfer to New List Previous Permit Number an <br /> Before Expiration -tp-1fY2) <br /> IV.T e of POWTS S tem/Com ane—f-evdce: Check nil that apply) <br /> ',Non-Prcssuriecd in-Ground U i'rc imaivcd In-Ground U At- mdc U Mound>24 in,ofsuimble soil U Mound<24 in,o'suitable soil <br /> U Holding Tank ❑Other Dispersal Component(explain) U Pmueelmemt Device(explain) <br /> V.Dis ersndITreatment Area Information: <br /> Design Flow(pd) Resign Soil Appac atio^Rate(gpdso OiapersalArca Required(soDispersal Arca Proposed(so System Elevation <br /> 5-0 6so 9 . a <br /> VI.Tank Info Capacity in Total 4 O Manufacturer <br /> Gallons Gallon Units w o v - o <br /> Ncw Ten4s Esb ng Ta^ka u N x <br /> a`Uvo a, O n. <br /> sqtxcaIfdhaFdsnx6, 1411,90 <br /> Dosing chamber C�o <br /> VII.Responsibility Statement- 1,the undersigned,assume respomdhilit,for Installation of the PDWTS show.on the attached plans. <br /> Plumber's Name(Prod Plumber's Signorina MP/MPRS Number Business Phone Number <br /> WADE RUFSHOLM i p 227691 715-349-7286 <br /> Plumber's Address(Street.City,State,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 <br /> VIII.Count /De artment Use Onl <br /> Approved ❑ Disapproved permit Pec Date Issued Issuing Agent Signature <br /> $ 325. vo <br /> ❑ Owner Given Reason for Denial _. <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> JUN - 92014 <br /> ArmenmenmPtaoe M.nsr.rme rratzm.ne rabmnmme tn.nrr ums.n vn.r.alater m.na g�J�j TMOUNIY' <br /> ZONING <br />