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b`�� f�anigvT County <br /> / 1 Safety and Buildings Division 4/-/1) <br /> j + (j 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> P.O. Box 7162 <br /> Madison,Wl 53707-7162 tL <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 <br /> purposes in accordance with the Privacy Law,s.15.04(()(m,Stats. C ��4� n <br /> I. Application Information—Please Print All Information ! <br /> Property Owner's Name Parcel# 07 p 3 0? V 0 / <br /> Property Owner's Mailing Address Property Location /e <br /> a S9 15f /V02 /0 t4 Govt.Lot '5- <br /> City, <br /> City,Stale Zip Codeq Phone Number y4, Y4, Section',23 <br /> (circle one) <br /> II.Type of Building(check all that apply) 3 T ,y0 N; R /7 E o&Lot# <br /> or 2 Family Dwelling—Number of Bedrooms a Subdivision Name <br /> �— Block# <br /> ❑Public/Commereial—Describe Use _ <br /> ❑City of <br /> ❑State Owned—Describe Use r^ CSM Number ❑ Village of / <br /> V/ s/ Y ATown of <br /> IIL 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. ❑ Permit Renewal ❑Permit Revision ❑Change of Plumber 1 ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> 1V.Type of POWTS System/Component/Device: Check all that apply) <br /> ❑Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade A 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(s� Dispersal Area Proposed(sf) System Elevation <br /> y�a � � y6.s- <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units <br /> New Tanks Existing Tanks `'�" c .3 a <br /> U rn y zn w C7 a. <br /> Septic or HDSdimrTa* j0D �(JQ <br /> Dosing Chamber e) dp <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature 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.Coun /De artment Use Only <br /> FAroved Disapproved <br /> Permit Fee Date Issued Issuing A t ignature <br /> ❑ b <br /> ❑Owner Given Reason for Denial <br /> II{,Conditions of Approval/Reasons for Disapproval <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 a 11 inches in size <br />