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County <br /> \ ty <br /> Safety and Buildings Division <br /> /) p -� 201 W.Washington Ave., P.O.Box 7162 Sanitary Permit Number(m he filled in by Cal <br /> 4 SPS, -� Madison,WI 53707-7162 <br /> S'anit'ary Permit Application <br /> state'rraasaatiupn,N`ninb/cr _ <br /> In accordance with SPS 38321(2),Wis,Arm Code,submission at this for.to the appropriate governmental unit ;?,? (/JY� <br /> is required prior to obtainings snnimry permit. Note Application forma for state-owned POWTS are submitted to Project Address ni'diPfercntimm muilingaddress) <br /> the Department of Safety and Professional Se'T Personal information you provide maybe used for secondary <br /> purposes <br /> o a n accordance with the privacyLaw,s. 15 04 1 m,Stats. 2(,,q'5( �1 / p/ <br /> 1. Application information-Please Print All Information Aid J.7 <br /> Property Owner's yNName -//- /^ // II ParcelI x�aey 0rJ-MVe b2•(aoP <br /> �E_/ Ct _55 ?_.-� -01 <br /> -2- - _o '(00-0! <br /> Property Owner's Mailing Address Property Location <br /> 'z 6 Y s l O/er/3 15- Govt.Lou_ <br /> City,StateCode CojeNT�N; R <br /> e ) Phone 'G'Number e� Oci Y, .SQJ Segion <br /> / 1 <br /> H.Type of Building(check all that a p ply) Lot 7 �b Eo[5yJ <br /> IAD or 2 family Dwelling-Number of Bedrooms I Subdivision Name <br /> Block 4 <br /> ❑Public/Commercial-Describe Use �— <br /> -- ❑City of <br /> U State Owned-Describe Use CSM Number ❑ villege of <br /> gown ar�Ylu<'=Ns�-t) <br /> ill.Type of Permit: (Check only one hos on line A. Coin p lete line Rif applicable) <br /> A. ❑ Now System X-Reptacorcm,System ❑TreatmenVl bolding Took Replacement Onto IJ Other Modificsum,to Existmg System(explain) <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑Parent'I mosfa to New List Previous Permit Number and Date Issued <br /> Before Bxpimtihn Owner <br /> IV.Type of POWTS System/Component/Device: Check all that a I <br /> ❑Non-Prasinaed lapround E) Pressurised In-Ground U At-:rod. ;I�Mm d?24 in.of suitable soil U Mound 124 or ofsnindi .it <br /> ❑ Holding Tank ❑Other Dispeaal Component(explain) U Pretreatment Device(ex Idm <br /> V.His ersal/Treatment Are. Information: <br /> Design clow(gpd) Design Soil Applie tion Rete(gpdsQ Dispersal Area Required(st) Dispersal Arca Proposed(sp Sysmm Llcvazam <br /> 3C7 lJ 3cJ Cl � Oli 78. 3 <br /> Vt.Teak Info Capacity in Total Hof .Manufacturer <br /> Gallons Gallons Units V $ 9 <br /> New Yanks Eselmg Tanks 7` yz 2 $ Pd <br /> Septic or HYk�ne'fT k 5-0 75-0Lil C_ <br /> Dpsnr(bomb" <br /> VII.Responsibility Statement- I,the ttnderstgned,assume responsibility fornstallatien of the POWTS shown on the attached plans. <br /> mbO <br /> Plumber's Name(PonPlumbcP Signator- t MP/MPRS Numher Business Phone Number <br /> WADE RUFSHOLM 222691 915-349-]286 <br /> LLC <br /> Plumber's Address(Sheet,City,State.Zip Code) <br /> PO BOX 514,SIREN,WI 5488 <br /> VIII.Count /De artment Use Only _ <br /> ❑Approved ❑ Disapproval Pemtit I ee Data Issued Issuing A 'gnnmre <br /> S 7S�2 z7�i1e 2013 <br /> ❑Owner Given Reaann for Denlai _ <br /> IX.Conditions ofApproval/lieasons fur Disapproval <br /> Amwh.anmplele M.ws J.,iM"ysrcm snn,m,mu to the moat,an(,nn mms,nm tens m.n P ter,I I inches of silo. <br />