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Vet" County <br /> /� �,y <br /> -n Safety and Buildings Division rVU/'nl '—J/ <br /> ? 0 + 201 W.Washington Ave., P.O. Boz 1162 Sanitary permit Number(in be fined in by Co,) <br /> SPS � 1 Madison,WI 53707-7162 <br /> Sanitary Permit Application State Tonsini Number n <br /> In accordance wish SPS 383.21(2),Wis.Adm.Code,submission nrthis form m the ii poanswe govemmemidl unit ✓oPx.�y Aev I(' <br /> is rcquimf pdorto obmining nsanitary'Permit. Nom:APPlicmiw loom fur smtenwncd POW'IS me xubmiueJm ProjeJct Add.Hi'dilTaent than madm,.ddreas) <br /> the Department of Sarety and Professional Smies. Personal information you provide may ba used lot secondary a <br /> p.m.,in avac accordance with the PriIA.,s. 15 M 1 m,Stats. / <br /> I. Application Information—Please Print All Information <br /> PwVOwne 's Name ? Parcel ao' -C' ,2.3 8 .-0 <br /> e/)')HNII) �3 oS-oa:i - a,2oovo <br /> Property Owner's Mailing Acidness - Vropeny lAintim yry:CV4-uo1-03.900 <br /> 1,23 S V,eGJ con.Let <br /> CiIy,SWte // 1 Zip Code PM1one Number g, S, SttdonL <br /> S � E <br /> Yo/ 7 _N; R15- U" <br /> {Da{.�Type of Building(check all that apply) Lot q <br /> KI or 2 Family Dwelling—NuBedrooms <br /> Number of Bedoy Subdivisian Name <br /> ekKk a <br /> D Public/Cammereinl—Describe Use �- El Cit,of <br /> ❑State Owned-0.xcribc U. CSM Number [Ivillneol' G <br /> '1/z /0 asy J4LT..mf 1 .4 <br /> Ill.Type of Permit: (Cheekanlyoneboxonline A. Complete line B if applicable) Q 1 q-: ao <br /> A' New System ❑ aepla¢mmdl System El Imatment/Holding Tank Replacrnient Only O Other MsaliGniun to Existing System(explain) <br /> B. 0Rermll Reoe d El Permit Revkinn OChangeorlhember ❑Pemtit'1mrsNrw Ncw Lia Pmvimn Penrod Number and Dole Issued <br /> ecforc F:xpimtinn Owner <br /> IV.Type of PORTS System/Component/Devi at apply) <br /> Non-Prcssuriud In-Ground D Pre....i,ed In-Umund 0 AI-G,ade 0 Mnund>24 in.W mimble snit 0 Mound'24 inorsuimhle snit <br /> O Holding rant, D Other Dispersal Conn xment(explain) O Preueabnent Deviee(explain) <br /> V.Dis eriali frealme at Area Information: <br /> Design Flux(gpd) Iksign Soil Application Rete(gpds0 Dispersal Area Required(sp Dispersal Are.Proposed(in Slelin Iilcvmkm <br /> S5o - 7 6 <13 6so %6 , 9 <br /> VI.Tank Info Capacity in Tocol 4 of Mxnumann r <br /> Gallom Gotten Units <br /> New Tants li.ann,lanks RR 3 <br /> U y ioU a <br /> Septa arlWWMy$ank �� 11 �L7t7� <br /> Dosing cmnlb> <br /> VII.Responsibility Statement- 1,The anders0ed,assume responsibility for insiallmimt of the PDWI'S Ali-is on the.1 plum. <br /> Plumber's Name(Prin) Plumber's SignmurcMI'IMI'RS Numhar Businexs Phune Number <br /> WADE RUFSHOLM / 2206Y1 715-349-7286 <br /> Plumber's Address(Sheet,City,Smte,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 <br /> VII ountviDe mrtment Use Only <br /> Approved DDisapproved Yemlitlie Dam Issued Issuin mSignmun <br /> D Ow.ef Oren Reason fin Denial s 325 ?��a 2,20IX.Conditions of ApprovallReasons for Disapproval <br /> Aman 1oomm.m14—rer di—y,mm..I eobmino m.1:... ony on r•x.nor I—Oun 8 In.11 mmr:is si.. <br />