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i carni ' <br />County <br />0 <br />�: Safety and Buildings Division <br />�-f r <br />r'N <br />Sanitary Permit Number (to be filled in by Co.) <br />1400 E Washington Ave <br />S P I� P.O. Box 7162 <br />5 AN -) - O S <br />S <;' Madison, WI 53707-7162 <br />sStO �� <br />Sanitary Permit Application <br />State Transaction Number <br />30 7WD9 <br />In accordance with SPS 38321(2), Wis. Adm. Code, submission of this form to the appropriate governmental unit <br />Note: Application forms for state-owned POWTS are submitted to <br />Project Address (if differeint an niRiling 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 />purposes in accordance with the Privacy Law, s. 15.041)(m), Stats. <br />I <br />% <br />���s/� a :S-330 <br />Parcel # p % Q <br />I. Application Information - Please Print All Information <br />Property Owner's Name f / <br />0C) <br />Pro�peerty Owner's Mail g Address �) n /� / <br />'7 O57 4 <br />1571z /1)/(/ �� f7I` T <br />Property Locatiton <br />Govt Lot <br />(� <br />'/'/., Section 2 S <br />(circle one) <br />City, State <br />Zip Code <br />Phone Number <br />G i iG C /f Ll e <br />S /n% <br />S O <br />7A3 - Y� ,� C'91 <br />TN; R =Eo <br />f <br />II. Type of Building (check all that apply) / <br />l <br />Lot # <br />� <br />Subdivision Name � <br />�14 or 2 Family Dwelling - Number of Bedrooms <br />I <br />Block#�- <br />❑ City of <br />❑ Public/Commercial -Describe Use r - <br />-' <br />El Village of - <br />CSM Number <br />❑ State Owned -Describe Use <br />Town of /�%2 L ti C -'J <br />111. '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 />❑ Other Modification to Existing System (explain) <br />B. <br />❑ Permit Renewal <br />❑ Permit Revision <br />❑ Change o£ Plumber <br />❑Permit Transfer to New <br />List Previous Permit Number and Date Issued <br />Before Expiration <br />Owner <br />IV. T <br />e of POWTS S stem/Com onent/Device: Check all that ap l <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/Treatment Area Information: <br />Design Flow (gpd) <br />Design Soil Application Rate(gpdsf) <br />Dispersal Area Required (st) <br />Dispersal Area Proposed (sf) <br />System <br />VI. Tank Info <br />VI. <br />Capacity in <br />Total # of Manufacturer <br />c <br />Gallons <br />Gallons Units2 <br />n U - <br />W U VN <br />w <br />m <br />New Tanks Existing Tanks <br />o ;; 2 <br />a 0 y <br />Y .2 <br />ra is C7 <br />P <br />Septic or Holding Tank <br />cJ <br />Dosing Chamber <br />VII. Responsibility Statement- 1, the undersigned, assume responsibility for installation of the POWTS shown on the attacbed plans. <br />Plumber's Name (Print) <br />Plumber's Signature <br />MP/W] S Number <br />Business Phone Number <br />WADE RUFSHOLM <br />- <br />227691 <br />715-349-7286 <br />Plumber's Address (Street, City, State, Zip Code) <br />PO BOX 514, SIREN, WI 54872 <br />U. Coun /De artment Use Only <br />Approved <br />❑ Disapproved <br />Permit Fee DO <br />Date Issue d <br />Issuing Agent Si <br />$ 3 7 �� <br />Q' <br />-lot <br />EJ Owner Given Reason for Denial <br />O <br />IX. Conditions of Approval/Reasons for Disapproval D <br />SJ:l/ z ✓ .� eo%oa�+-► I/$ e �i� , • r. <br />MAR 12 2018 <br />1 <br />Attach to complete plans for the system ano suntan to me ♦.00nty omy on paper nuc less man o — a a■ 1 wvw- . 1 <br />ZONING <br />