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��cxRr•,rN�T <br />county <br />Safety and Buildings Division <br />1400 E Washington Ave <br />Sanitary Permit Numbe (to be filled in by Co.) <br />ON COMP <br />TERNS P.o. Box <br />C�i�DVl 53770707 <br />6)CA&LIG <br />—7162 <br />Sanitary Permit Application <br />State Transaction Number <br />�- q S 70 <br />In accordance with SPS 38321(2), Wis_ Adm. Code, submission of this form to the appropriate governmental unit <br />1� I <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 />q Rd 7o <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 # b 7 0 <br />Property Owner's Mailing Address <br />Property Location 0 c_ <br />P0 'J ON,/ / f <br />-15� <br />Govt Lot <br />Lc9 /,, , 560 /,, , Section �---�— <br />Ci State <br />Zip Code <br />Phone Number j„5 <br />I/V <br />13/j <br />J �j F� _ U <br />q (circle ong , <br />T 6 N; R l ' E o W�,) <br />H. Type of Building (check all that apply) <br />Lot # <br />Subdivision Name <br />❑ 1 or 2 Family Dwelling — Number of Bedrooms <br />*ublic/Commercial — Describe Use C R /'' � rc 4 ^1 c <br />Block # <br />— <br />❑ City of <br />❑ State Owned — Describe Use <br />❑ Village of ^� <br />CSM Number <br />V 1 l /0 2, <br />OLTon of <br />III. Type of Permit: (Check only one box on line A. Complete line B if applicable) <br />A. <br />*ew System ys <br />❑Replacement System <br />❑ Treatment/Holding Tank Replacement Only <br />[I 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 apply) <br />,Non -Pressurized In -Ground ❑ Pressurized In -Ground ❑ At -Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil <br />❑ Holding Tads ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain) <br />V. Dispersal/Treatment Area Information: <br />Design Flow (gpd) I <br />Design Soil Application Rate(gpdsf) <br />Dispersal Area Required (s0 <br />Dispersal Area Proposed (sf) <br />System Elevation <br />3�0 31 <br />y200 <br />g94),SY <br />VI. Tank Info <br />Capacity in <br />Total <br /># of Manufacturer <br />Gallons <br />Gallons <br />Unitso ,b, <br />2 <br />New Tanks Existing Tankso <br />2 4)m <br />a U in y rn w C7 <br />M <br />w <br />Septic or Holding Tank <br />�<—S 0 <br />1 r <br />Dosing Chamber <br />VII. Responsibility Statement- I, the undersigned, assume responsibilitylJfor 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 />,� I <br />227691 <br />715-349-7286 <br />Plumber's Address (Street, City, State, Zip Code) <br />PO BOX 514, SIREN, WI 54872 <br />II. Coun /De artment Use Only <br />Approved <br />❑ Disapproved <br />Permit Fee C <br />Date Issued <br />Issuing Agent Sign <br />❑ Owner Given Reason for Denial <br />�7 <br />VL Conditions of Approval/Reasons for Disapproval <br />���/ova L • s �or S9 s,'fes fob /1%�i'�WPS� t7i��J{/�riL ��t'a . %� SPct So�.aL Use �wL� <br />Lois 1>v 2 %o ie Gon�b%Ntof a Z . <br />Attach to complete plans for the system and submit to the County only on paper not less than 8 in x 11 inches in size <br />