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jVA Comn <br /> � Safety and Buildings Division <br /> 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> P P.O. Box <br /> Madison,WI 53707-7162 50$01 c�lJ - <br /> Sanitary Permit Application State Transact ion Number <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 sanitarydpermit. Note:: Application forms for state-owned POWTS are submitted to Project Address(if different than mailing ess) <br /> the Department of Safety and Professi ill Services. !Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s. 15.04 1 m,Stats. a9,4�31 z <br /> I. Application Information—Please Print All Information ✓ !— <br /> Property Owner's Name Parcel# <br /> e /-t-v 4 Sa.j <br /> Prft <br /> oper/y Owner's M Cling Address. ` Property Location <br /> L O U� Govt.Lot <br /> City,State Zip Code Phone Number <br /> /., Section <br /> ` le one <br /> Type of Buil ing(check all that apply) Lot# T�_N; R (�cyc�E Y� <br /> or 2 Family Dwelling-Number of Bedrooms 3 Subdivision Name I� / <br /> -� Block# #/f w5e=o irl L/� S/�e r <br /> ❑Public/Commercial-Describe Use !-' <br /> j ❑ City of <br /> CSM Number <br /> ❑State Owned-Describe Use ❑ Village - y,L� <br /> of <br /> IIL Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' Y6cw System ❑Replacement System ❑ Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑ Perm t evision 11 Change of Plumberr0wner <br /> ertnit'fransfer to New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration �' j ! <br /> IV.Type of POWTS System/Component/Device: Check all that appi <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) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> moo / 7 4/ay p6 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units c $ <br /> New Tanks Existing Tanks <br /> V m h rn <br /> Septic or Folding-Tack tS <br /> Dosing Chamber C <br /> VIL Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature ' / MP/MPRS Number Business Phone Number <br /> WADE RUFSHOLM / �, �.���� 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 <br /> VIII.Coun /De artment Use Only <br /> Permit Fee Date Issued Issuing A Signature <br /> Approved ❑ DisapprovedI $ 7S' oo O IS <br /> ❑ owner Given Reason or Den a` <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> n� �S Attach to complete plans for the system and submit to the County only on paper not less than 8 rR x i I inches in size <br />