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i �szaiW, Co <br /> Safety'and Buildings Division L1/"ItJ� <br /> D mil 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co_) <br /> 01 P.O.Box 7162 r' <br /> '3 Ste,, Madi on,Wl 53707-7162 -J / <br /> Ste4 3 <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 maybe used for secondary <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stars_ <br /> L Application Information-Please Print All Information <br /> Property Ovigers Name Parcel#O 7 j .2 9 <br /> ZV An (fcd ,v/� O <br /> Property Owner's Mailing Address Property Location <br /> e 7 7 7 Govt Lot <br /> City,State Zip Code Phone Number y, yti Section�� <br /> �" V_51e (circle one <br /> ,:`j T N, R ff,�E o W <br /> II.Type of Buildin (check all that apply) Lot# <br /> �J or 2 Family Dwelling-Number of Bedrooms r Subdivision Name <br /> Block# 0� <br /> ❑PubliclCommercial-Describe Use ❑City of <br /> ❑State Owned-Describe Use CSM Number (� ❑Village of <br /> VOZ /2 s 3 7 Town of <br /> D1 Type of Permit: (Check only one box on line A. Complete line B if applicable) / <br /> A. KNew System ❑Replacement System ElTreatmerrt/Hblding Tank Replacement Only ❑Other Modification w Existing System(explain) <br /> B. ❑`Permit Renewal ❑ Permit Revision ❑Change of PI Limber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: Check all that app1 <br /> ❑Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grad ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> KHolding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> VI.Tank Info Capacity in Tqtal #of Manufacturer <br /> Gallons Gallons Units <br /> New Tanta E ataig Tads c d R <br /> a U in �, ti 7ve C7 P. <br /> 2MMncHolding Tank <br /> Dosing Chamber <br /> VIL Responsibility Statement-4 the undersigned,assume responsibility for installation of the POWTS shown on the attached plans- <br /> Plumber's Name(Print) Plumber's Signature MPA4PRS Number Business Phone Number <br /> WADE RUFSHOLM 227691 715-349 7286 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO 13OX 514,SIREN,WI 54972 <br /> VIIL Coun /De artment Use Only <br /> Approved ❑Disapproved Permit Fee Date Issued Issuing Agent ignaluce <br /> ❑ Owner Given Reason for Denial 7 f <br /> Uf Conditions of Approval/Rensons for Disapproval <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 r/a x 11 inches in size <br /> i <br />