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�iAR, <br />County /Mx st <br />Safety and Buildings Division <br />4/'itf 367 <br />0 <br />P <br />1400 E Washington Ave <br />P.O. Box 7162 <br />Sanitary Permit Number (to be filled in by Co.) <br />S <br />Madison, W 153707-7162 <br />Sanitary Permit Application <br />StateTransaction Number <br />In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental unit <br />/VW <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 />oses in accordance with the Privacy Law, s. 15.04 1 m , Stats. <br />Y I <br />Al. <br />I. Application Information - Please Print All Informations <br />PropertyOwner's Name <br />I <br />Parce <br />_l # o <br />�� rm <br />Property Owner's Mailing Address / <br />Pp LN <br />Property Location R0 c <br />/ c) ry <br />Govt. Lot ✓ <br />/,, Section <br />City, State <br />Zip Code <br />Phone Number <br />�(n -v/a, <br />�e-��/�� t\/T IJ <br />��� � <br />T tJ N; R %sL Eoircle n-1 <br />II. Type of Building (check all that apply) <br />Lot # <br />i k or 2 Family Dwelling - Number of Bedrooms <br />�' <br />Subdivision Name <br />-- <br />Block # <br />❑ Public/Commercial - Describe Use <br />❑ City of ^ <br />❑ State Owned - Describe Use <br />❑ Village of <br />CSM Number <br />y_ <br />own of Z- Y+ ( O <br />III. Type of Permit: (Check only one box on line A. Complete line B if applicable) <br />A' <br />❑ New System <br />y <br />JRe lacement System <br />p y <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 />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/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 />0 <br />7 <br />y3 <br />6 Y, <br />9s; <br />, <br />VI. Tank Info <br />Capacity in <br />Total # of <br />Manufacturer <br />Gallons <br />Gallons Units0 <br />o d <br />New Tanks Existing Tanks <br />0 <br />a U <br />inti rn w c'7 0, <br />Septic or iielthffg atik <br />v <br />D <br />I <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 <br />Signature ^ <br />MP/MPRS Number <br />Business Phone Number <br />WADE RUFSHOLM <br />�,�!/Q, <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 />❑ Disapproved <br />Permit Fee d <br />Date Issued <br />Issuing Agent Signa e <br />El Owner Given Reason for Denial <br />$ 7 <br />p / <br />IX. Conditions of Approval/Reasons for Disapproval <br />APPROV[D <br />Attach to complete plans for the system and submit to the County only on paper not less tha 1/2 i <br />SBD-6398 (80313) <br />OCT z s zoos <br />RI II3AI=T'T fInt tAITV <br />