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iottxFr.�r �,. <br />Safety and Buildings Division <br />County <br />Gr � <br />a � tT5 <br />1400 E Washington Ave <br />Sanitary umber (to be filled in by Co.) <br />.g1 <br />=�+ `� S 1= <br />P.O. Box 7162 <br />$L? IV 41 (0 y <br />Madison, WI 53707-7162 <br />rrr�� w <br />FF3SIE���4 <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 />Note: Application forms for state-owned POWTS are submitted to <br />Project Address (if different than mailing address) <br />is required prior to obtaining a sanitary permit. <br />the Department of Safety and Professional Services. Personal information you provide may be used for secondary <br />in with the Privacy Law, s. 15-04(1)(m), Stats. <br />d� J �D % %�Ak <br />purposes accordance <br />x <br />1. A plication Information — Please Print All Information <br />Parcel # 07%S 6 <br />Property Owner's Name <br />e. <br />Property Location <br />Mss <br />Property Owner's 'ailing e <br />s <br />Govt Lot <br />City, State Zip Code Phone Number <br />y,, �/., Section %5 <br />( / / b / <br />Ver Gro�re fS /V 5 �� b �sf 33 3 <br />Lot # <br />rcle one) <br />T y'O N; R EorW <br />H. Type of Building (check 91 that apply) <br />1 2 Family Dwelling —Number of Bedrooms <br />�� <br />Subdivision Name l <br />/� <br />``�� )C/fo i- <br />or <br />Y- <br />/ / <br />Block # <br />❑ City of <br />❑ Public/Commercial — Describe Use <br />❑ Village of <br />CSM Number <br />❑ State Owned — Describe Use <br />A Town of J�aA) <br />III. Type of Permit: (Check 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 />ElPermit Renewal <br />ElPermit Revision <br />ElChange of Plumber <br />ElPermit 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 apply) <br />❑ Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound > 24 ur_ 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(gpdst) Dispersal Area Required (s Dispersal Area Proposed (sf) System Elevation <br />VI. Tank Info Capacity in Total # of Manufacturer <br />Q U <br />Gallons Gallons Units -fl U y <br />v ^y a <br />New Tanks Existing Tanks o °E .2 <br />a. U rn y rn w C7 P. <br />Septic orHdMb**w*e--5 <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) Plumber's Signature MP/MPRS Number Business Phone Number <br />227691 715-349-7286 <br />WADE RUFSHOLM <br />Plumber's Address (Street, City, State, Zip Code) <br />PO BOX 514, SIREN, WI 54872 <br />VIII. Coun /De artment Use Only <br />Permit Fee <br />Date Issued <br />Issuing Agent Sign <br />Approved <br />❑ Disapproved <br />$ ? <br />7 <br />Owner Given Reason for Denial <br />El Owner <br />IX. Conditions of Approval/Reasous for Disapproval <br />ECEIVE <br />_ o _ i ..r. $fA►e <br />Attach to complete pians for roe system ana SOOIInr w wa wuu,y ..u.y VN r -Fr I U 1017 <br />LU) <br />--- --- _ -- 13URNETT COUNT <br />ZONING <br />