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4 zi`T6 <br />Safety and Buildings Division <br />County <br />6r <br />ON E®MPUT€ <br />L� ffq.�p E Washington Ave <br />SCANNCUP.O. Box 7162 <br />Sanitary Permit Number (to be filled in by Co.) <br />IRS S AV/ <br />Madison, WI 53707-7162 <br />L"7 <br />�'"I 1 � <br />Sanitary Permit Application <br />State Transaction Number <br />In accordance with SPS 38321(2), Wis. Adm. Code, submission of this form to the appropriate governmental unit <br />Project Address (if different than mailing address) <br />is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are submitted to <br />the Department of Safety and Professional Services. Personal information you provide may be used for secondary <br />gQ�S•' <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 <br />Parcel # 0 7 0%2 <br />4, -,l/ /z <br />1 5'05- oeZ-o z9o�s0 <br />Property Owner's Mailing Address Q <br />Property Location <br />/ 3a S' 3s- <br />Govt. Lot 02 <br />/,, �/. Section -2 3 <br />City, State <br />Zip Code <br />Phone Number <br />6 l r e A) � Y— <br /><Y <br />CL,9 7 -'7 <br />j oC <br />3 YY _75,Y5' <br />(circle one <br />T lt' N; R_/' �_Eof <br />II. Type of Building (check all that apply) <br />Lot # <br />Name <br />�lSubdivision <br />or 2 Family Dwelling -Number of Bedrooms <br />Block # <br />❑ Public/Commercial - Describe Use <br />❑ City of <br />❑ State Owned - Describe Use <br />❑ Village of <br />C c11J <br />CSM Number <br />,&Town of \-r,4 -S <br />III. Type of Permit: (Cbeck only one box on line A. Complete line B if applicable) <br />A. <br />New System <br />❑ Replacement System <br />❑ Treatment/Holding Tank Replacement Only <br />❑ Other Modification to Existing System (explain) <br />B. <br />❑ Permit Renewal <br />❑ Permit Revision <br />❑ Change of Plumber <br />❑ Permit Transfer to New <br />List Previous Permit Number and Date Issued <br />Before Expiration <br />Owner <br />IV. Type <br />of POWTS System/Component/Device: Check all that a l <br />In -Ground ❑ Pressurized In -Ground ❑ At -Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil <br />,P�Non-Pressurized <br />❑ Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain) <br />V. Dis ersal/Treatment Area Information: <br />Design Flow (gpd) <br />Design Soil Application Rate(gpdsf) <br />Dispersal Area Required (sf) <br />Dispersal Area Proposed (sf) <br />System Elevation <br />.. <br />, <br />�• <br />VI. Tank Info <br />Capacity in <br />Total # of Manufacturer <br />o <br />Gallons <br />Gallons Units a 2 1 <br />U <br />2 <br />New Tanks Existing Tanks <br />o 2 E!y � <br />U0 0, 0,y wC7 <br />� <br />C% <br />Septic or Holdicg.&enk- <br />/ _ <br />C t •�', 0. re, ­J eas;:�, ,:�> <br />Dosing Chamber <br />VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. <br />Plumber's Name (Print) <br />Plumber's Signature <br />MP/MPRS Number <br />Business Phone Number <br />WADE RUFSHOLM <br />n _ ) <br />(/l/ <br />227691 <br />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 <br />Permit Fee <br />Date Issued <br />Issuing Agent Signature <br />❑ Owner Given Reason for Denial 1 <br />3� S - 0 <br />1 ,�- -0 <br />3 S <br />IX. 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 81/2 x 11 inches in size <br />