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`ii;,uftu <br />County <br />_ <br />Safety and Buildings Division <br />Sanitary Permit Number (to be filled in by Co.) <br />S <br />1400 E Washington Ave <br />P.O. Box 7162 <br />j G <br />. _._ <br />Madison, WI 53707-7162 <br />Sanitary Permit Application <br />State Transaction Number <br />N4 <br />In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental unit <br />is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are submitted to <br />Project Address (if different than mailing address) <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 />Parcel # 0 7 Oil Z d <br />I. Application Information - Please Print All Information <br />Property Owner's Name <br />t <br />�]`f}� r'U <br />S O 00 O O D D <br />Property Owne fling Address <br />Property Location p G <br />SO <br />Govt. Lot <br />/4, Section <br />City, State <br />Zip Code Phone <br />Number/4, <br />12 _3 7 /,✓�7 q�Q <br />/ O <br />circle one <br />T% Q N; R E OtD <br />II. Type of Building4cleck all thaf apply) Lot <br /># <br />Subdivision Name <br />91 or 2 Family Dwelling -Number of Bedrooms ✓ <br /># <br />Block <br />❑ City of r-- <br />❑ Public/Commercial - Describe Use <br />�+ CSM <br />❑ State Owned - Describe Use <br />El Village of <br />gTown of �G <br />Number <br />F V/ <br />(J <br />III. Type of Permit: (Check only one box on line A. Complete line B if app icable) <br />`4' <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 of POWTS System/Component/Device: Check all that apply) <br />J9 Non-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/Treatment Area Information: <br />Design Flow (gpd) <br />Design Soil Application Rate(gpdsf) <br />Dispersal Area Required (sf) <br />Dispersal Area Proposed (so <br />System Elevation <br />75�0 <br />VI. Tank Info <br />Capacity in <br />Total <br /># of Manufacturer c <br />Gallons <br />Gallons <br />Units U B y <br />New Tanks <br />Existing Tanks <br />00 �? y 7 V <br />E U in h w C7 Ci, <br />Septic or Holding Tank <br />/C/5- <br />-Chamber <br />7-5 O <br />1757le <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 RUFSHOLM1 <br />11044 6�!� <br />227691 <br />715-349-7286 <br />Plumber's Address (Street, City, State, Zip Code) <br />PO BOX 514, SIREN, WI 54872 <br />II. Count /De artment Use Only <br />Approved <br />El <br />Permit FeeDate <br />$ O <br />Issued <br />Issuing Agent Signator <br />VI/Yo <br />❑ Owner Given Reason for Denial <br />y _ <br />IX. Co i 'Q-ns of JIMP Approval/Reasons for Disapproval <br />log <br />r ROVERN <br />Attach to complete plans for the system ano suormt to the County omy on paper nvi 1— .nan o i- ,, rr ...,..w ... <br />SBD -6398 (80313) <br />