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/9{P,1A2.1` <br />Safety and Buildings Division <br />county <br />>>� <br />1400 E Washington Ave <br />Sanitary Permit Number (to be filled in by Co_) <br />P_0. Box 7162 <br />Madison, WI 53707-7162 <br />�QQOZ�36 <br />SAN-17-/91-2 CST-r -6i <br />Sanitary Permit Application <br />state Transaction Number <br />31119:61 <br />In accordance with SPS 38321(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 />S I� <br />purposes in accordance with the Privacy Law, s. 15.0 1 m), Stats. <br />71" C) -5i tJi / h► <br />Parcel # C, 7 d d O! 3 3 <br />I. Application Information -)Please Print All Wormation <br />POwner's Name <br />ro <br />u C1 -rX,*M A s o J <br />so 5 ©� o�� oa <br />Property O is Mailing Add <br />Property Location <br />o?ooZ C ✓'� w L tJ <br />Got Lot 3 <br />y, /., Section �— <br />City, State <br />Zip Code <br />Phone Number <br />C / ZI j <br />� 5- 51(circle <br />one <br />II. Type of Building (check all that apply) <br />Lot # <br />Subdivision Name <br />(ytor 2 Family Dwelling -Number of Bedrooms <br />` <br />Block # <br />❑ Public/Commercial - Describe Use <br />❑ City of �- <br />❑State Owned -Describe Use <br />❑ Village Of <br />Vown <br />CSM Number <br />V'9 q <br />of <br />III. 'Type of Permit: (Check only one box on line A. Complete line B if appli le) <br />A. <br />%New System <br />Replacement System <br />❑ Treatment/Holding Tank Replacement Only <br />❑Other Modification cation to ExistingSystem (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 POAWS S stem/Com onent/Device: Check all that a 1 <br />❑ Non-Pressurized In-Ground ❑ Pressurized 1n-Ground ❑ At-Grade ❑ Mound 2:24 is of suitable soil X 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 />it Application Rate(gpdsf) <br />Design Soil <br />Dispersal Area Required (sf) <br />Dispersal Area Proposed (st) <br />System Elevation <br />5—p <br />isos <br />a <br />q 7 �vz <br />V1. Tank Info <br />Capacity in <br />Total <br /># of Manufacturer <br />[ z7 <br />Gallons <br />Gallons <br />Units 2 <br />New Tanks Enstiag Tanks <br />ami o L L ° cd <br />cl) ii C7 w <br />Septic or Hbiding-Tank <br />^ _ <br />9A) <br />Dosing Chamber <br />D <br />VH. 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 RUFSHOL.M <br />/ <br />227691 <br />715-349-7286 <br />Plumber's Address (Street; City, State, Zip Code) <br />PO BOX 514, SIREN, WI 54872 <br />VIII. Conn /De artment Use Only <br />Approved <br />❑ Disapproved <br />Permit Fee <br />Date Issued <br />Issuing Agent Signature <br />❑ Owner Given Reason for Denial <br />DL Conditions of, A/.pprovaUReasons jor Disapproval pp <br />�� c/a's%o v r �ov vo( sly <br />Vol' { %old,%✓ a A"' l'rn i /�21� Mi <br />J <br />Attach to complete plans for the system and submit to the t;omtty only on paper not less man 0 ALL z l 1 nlCneS rn s <br />