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`119 RT.N T County <br /> + � Safety and Buildings Division G r/t) 2 <br /> $ " 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> is PS P.O. Box 7162/ 77� _ <br /> ''tom r• Madison,WI 53707-7162 n <br /> SKiNP��'�F SAI vl — <br /> Sanitary Permit Application State Transact ionNumber <br /> In accordance with SPS 383.21(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 <br /> purposes in accordance with the Privacy Law,s. 15.04 1 m,Stats. <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel N 07 05V of 3 7 <br /> U AT/' S 4 --,+ e-.u) Yo oozy paoot*:71a <br /> Property Owners Mailing Address / Property Location 0 <br /> a 1 v <br /> 4,q <br /> Gr!/ / c_ <br /> Govt.Lot <br /> CState Zip lC�od <br /> C, <br /> pe Phone Number Xy4 �/ti r Section <br /> reC <br /> d e r/C I LIQ* 3 7 � � circle one <br /> H.Type of Building(check all that apply) Lot# T---L—N; R �6 E of <br /> or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> ��- Block 4 <br /> ❑Public/Commercial-Describe Use ❑City of <br /> ❑State Owned-Describe Use <br /> CSM Number ❑ Village of <br /> 1 own of / e— <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A* ❑New System 4eplacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal Ll Permit Revision El Change of Plumber El Permit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration IOwner <br /> IV.Type of POWTS System/Component/Device: Check all that apply) <br /> ❑Non-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(gpdsf) Dispersal Area Required(so Dispersal Area Proposed(st) System Elevation <br /> C) <br /> VI.Tank Info Capacity in Total 4 of Manufacturer <br /> Gallons Gallons Units a v ` N T <br /> New Tanks Existing Tanks <br /> CL U �n h y ii C7 t1 <br /> $Vkmr Holding Took <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) Plugtber's Signaturwl MP/MPRS Number Business Phone Number <br /> WADE RUFSHOLM rj�tC/I c�y� 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 <br /> VIII.Coun /De artment Use Only <br /> Approved <br /> Disapproved Permit Fee <br /> < Date Issued Issuing Agen gnature <br /> ❑Okvner Given Reason for Denial $ 75 y 0� y 7' LA41 <br /> UC.Conditions of Approval/Reasons for Disapproval i5toWerS /}�rttrMCwf To P Ptc'Ks up �Yorrt Um e r o w <br /> 7-9-rs �A� W-za s�«f o.v. <br /> Attach to complete plans for the system and submit to the County only on paper not less than a 112 111 inches in size <br />