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/e+azaifl;T <br />-Noll. <br />Safety and Buildings Division <br />County,2 <br />`'7 Q , t�XTItnn <br />0(V C <br />Ave <br />OMPUT <br />Sanies Permit Number (to be filled in by Co.) <br />P <br />` S <br />S1 <br />!?� , <br />Madison, WI 53707-7162 <br />r <br />Sanitary Permit Application <br />State Transaction Number <br />an <br />� ? 7 " <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 />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 C Fj �; b {J n n ivT <br />Parcel # C>7 c� o? 3 <br />�% 5 e- o <br />ca 3 C9 0 o 015e6,0 <br />Property Owner s Mailing dd <br />Property Location loe- / <br />� <br />Govt Lot <br />SGcI y,, :5-ed Y., Section .3V <br />City, State <br />Zip Code <br />Phone Number <br />-5-re i �. t-)1- <br />5 `/ 7 <br />(circle one <br />T � / N; R/ � E ot� <br />II. Type of Building (check all that apply) � <br />Lot # <br />"f <br />Subdivision Name <br />❑ I or 2 Family Dwelling —Number of Bedrooms <br />-- <br />3 S / <br />Block # <br />" Public/Commercial —Describe Use Q/901 t� 6� <br />❑ City of <br />❑ State Owned — Describe Use <br />❑ Village of -- <br />CSM Number <br />5 <br />V// P <br />Town of /i9 <br />III. Type of Permit: (Check only one box on line A. Complete line B if applicable) <br />A. <br />Yl-,New System ys <br />El Replacement System <br />❑ Treatment/Holding Tank Replacement Only <br />❑Other Modification to Existing System (explain) <br />B. <br />❑Permit Renewal <br />IJ Permit Revision <br />[I Change of Plumber <br />El Permit Transfer to New <br />List Previous Permit Number and Date Issued <br />Before Expiration <br />Owner <br />IV. Type of POWTS System/Component/Device: Check all that apply) <br />XNon-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil <br />❑ Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain) <br />V. Dispersal/Treat ent 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 />151 <br />15 <br />3,5'c- C.) <br />,0 <br />VI. Tank Info <br />Capacity in <br />Total # of Manufacturer <br />Gallons <br />Gallons Units �, o <br />New Tanks Existing Tanks <br />w c P <br />w U in H <br />Y <br />co w C7 <br />a <br />Septic or HMft-Tank <br />_?30 U <br />Dosing Chamber <br />VII. Responsibility Statement- 1, 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 />,) ` <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 />lI. Coun /De artment Use Only <br />Approved <br />❑ Disapproved <br />Perm?ityFee�O <br />$ <br />Date Issued <br />Issuing Agent Si <br />11Owner Given Reason for Denial <br />J / '� ' <br />Ix. Conditions of Approval/Reasons for Disapproval C lepod' T' S OW S `i /- �g Aq i5 /n d <br />Soi va 17e ox a14 W.' <br />7 i s Cr�'il'aa Gv'�%>'>°�ox a�' �/8:` lellfl 4,41,11AI v a,� o <br />Gav>% overGet!Ls. <br />tt p <br />Z-I.r /w a %d Se Co"n LIV4 " <br />Attach to complete plans for the system and submit to the County only ou paper not less than 8112 z 11 inches in size <br />