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Cy <br /> Safety and Buildings Division County <br /> D_S 1400 E Washington Ave Sammry PermitNumber(to her filled in by Co.) <br /> .•'1µ'e P `^~ P.O. Box 7162 <br /> SS <br /> a\/ Madison,WE 53707-7162 <br /> Sanitary Permit Application SurfTracrescamtNtind, r <br /> -� <br /> In ar.mdare wi0 SPS 383.21(2). Wes. Adm. Code,submission of this form m the appmprime g ,marm x.1 <br /> unit is required prior to obtaining a sormory permit. Note: Application farms for sutrowned POWTS are Pr meetAddrcvs Ifdrent 1mn mailng address) <br /> vubmined to the Department of Safety aM Yrofessl real Services. Personal information you provide may be <br /> used for seemalary purposes in areaut arne with the Privacy Law,s. 15.0i(D(m.Stats. t'I <br /> L Application Information-17eaee Print All Information W•&I kq <br /> Prnryxty Owner's Name Parcel# 04_Ca�-a_g1a-EL,— <br /> Almr�l #�3�a5 _ 5.S-3 <br /> Property Owner's Ma fling Address / Property Location <br /> am Cr � y� Gm.t. Litt <br /> Ci .Sute Zip Gxle Phnne Number t Ir_ C„1 <br /> �\ �F.oJJJ- F,Seninn <br /> V (circ�le one) <br /> -IsIL{.Ts pe of Builth check all that apply) Lot M T 40 N: R I. <br /> `C1i <br /> pl nsc.ca'amily Dwelling-Ninderof Rcdratms ( Subdirision Nmne <br /> Block# <br /> ❑Nblie/Commercial-Describe Use <br /> ❑ Cin of <br /> D Sue Owed-Describe Use CSM 'Number D Village of <br /> V. a3 P, *Townof r^a la <br /> III.Tc n of Permit: (Check only one box on line A. Complete line B if applicable) <br /> New System D Replacement System D Treatmen✓HnWing Tank Replacement Only' D Other Modification to Existing System(explain) <br /> B. 61 Prou m Renewal D Permit Revision ❑ Change of ❑Permi,Transfer m New List pre,ran,Permit Nmnbcr and Date Isued <br /> Before Expiration plunder Owner <br /> IV. Tvpe of PORTS System/Cam nenl/Deyice: (Check all that apply) <br /> ❑ Nor Pressariied In-Ground D Pressurized InGmmxl D At Gradt mmd L 24 in.of suitablesoil D Mound < 24 ir.of suitable soil <br /> ❑ holding fork D Other Dispersal Component(explain) D Prettrument Device(explain) <br /> V. Disper,tairTrealment Area Information: <br /> Design Plow(gpd) Design Soil Application Rate(gos0 Dispersal Arca Raptured(s0 Dispersal Area PfoposW(s0 System Elevation <br /> V1. Tank Into Capacity in Tout #of Manufanmer <br /> Gallons Collins Tons - _ <br /> Nsv yanks Existing Duty 2 _ <br /> as <br /> iU LG <br /> Septic Holha,T.nkrn in <br /> qy�� <br /> losing Chnci c, W11 <br /> VII. Responsibility Statement- L the undersigned,a<st fir resporuibilit installation n of the PORTS shoes au the mmched plain. <br /> Plummer's Name(Pain q Plumhr' Sigw tore MP/MPRS Number Business Phone Number <br /> WADE RUPSHOLM 221691 ]I5-349-]2A6 <br /> Plumlrer's Address(Street .City.Sum.Zip Code) <br /> 1'O BOX 514 SIRES,WE 54872 <br /> VIP.County/De artnienl Use Only <br /> f <br /> proved ❑ Dktpproved <br /> Permit Pec Date 16sued Bsuing Agent Si mantra S 1I <br /> 110.....Given Reawn far Rnial ��p "(—fJ <br /> IS.Conditimts of Approval/Remour s for Disapproval V D <br /> OCT 2013 <br /> e(R1m L : x,sl INTY <br /> Anarn to yornpleur plans for the slen and submit to the Counts um on wPr not 1—mean 9t l OIMNG <br /> SBD-6398(R0313) <br />