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_ <br />.r Safety and Buildings Division <br />County <br />; <br />1400 E Washington Ave <br />Sanitary Permit Number (to be filled in by Co.) <br />S �. i= P.O. Box 7162 <br />l ( CST- 13 - o � <br />SN' Madison, WI 53707-7162 <br />1, <br />Sanitary Permit Application <br />State Transaction Number <br />307 -7 96 Ll <br />In accordance with SPS 38321(2), Wis. Adm. Code, submission of this Than to the appropriate governmental unit <br />Note: Application fomes for state-owned POWTS are submitted to <br />Project Address (if different than mailing address) <br />is required prior to obtaining a sanitary permit <br />the Department of Safety and Professional Services. Personal information you provide may be used for secondary <br />1124/ 7Q lj <br />purposes in accordance with the Privacy Law, s. 15.04(l)(m), Stats. <br />7 3 `�` /� - .5 <br />Parcel # C O <br />L A plication Information -Please Print All Information <br />Property Owner's Name <br />.�� <br />Property Owner's Mailing Address <br />Property Location <br />d 2 6/ i �� <br />Govt Lot <br />/4, Section <br />(�rcle one <br />City, State <br />C <br />Zip Code <br />Phone Number <br />�j <br />j <br />l <br />/L <br />�- 31/ <br />F� / s ��n <br />T N; R �5 E aV <br />11. Type Building (check all that apply) <br />'1'i 2 Family Dwelling -Number of Bedrooms �� <br />Lot # <br />-7 <br />/ <br />Subdivision Name <br />or <br />% <br />—Block <br /># <br />El city of <br />_ <br />❑ Public/Commercial -Describe Use <br />❑ State Owned - Describe Use <br />❑ Village of _ <br />p4'own of <br />CSMNumber <br />III. 'Type of Permit: (Check only one box on line A. Complete line B if applicable) <br />A. <br />New System <br />❑ Replacement System <br />❑ Treatment/Holding Tank Replacement Only <br />0 Other Modification to Existing System (explain) <br />B. <br />Permit Renewal <br />❑ Permit Revision <br />Change of Plumber <br />❑ Chan <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/Comp onent/Device: Check all that apply) <br />❑ Non -Pressurized In -Ground ❑ Pressurized Irr-Ground ❑ At -Grade B.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 (st) <br />System Elevation <br />VI. Tank Info <br />Capacity in <br />Total # of Manufacturer <br />Gallons <br />Gallons Units U g <br />N U V N y <br />in <br />New Tanks Existing Tanks <br />2 c E y <br />Septic or He c <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 />WADE RUFSHOLM <br />Plumber's Signature <br />MP/MPRS Number <br />227691 <br />Business Phone Number <br />715-349-7286 <br />Plumber's Address (Street, City, State, Zip Code) <br />PO BOX 514, SIREN, WI 54872 <br />Coun /De artment Use Only <br />�VIII. <br />Approved <br />❑ Disapproved <br />Permit Fee <br />$ O� <br />Date Issued <br />Issuing Agent Signature <br />❑ Owner Given Reason for Denial <br />3 �J ' <br />Y Z �� <br />IX. Conditions of Approval/Reasons for Disapproval <br />Alvl01 d Aqw t/ /v0 141"a L OCG T, 4N �!r✓N s N d/11A, <br />,41Z 7,— <br />Attacb to complete plans for tie system ani Snnmrt to me ♦,uunry omy -- p.Prr .ao A— ... , A •- <br />