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County ^ <br /> Safety and Buildings Division //�'y/^,� t! <br /> 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> P.O.Box 7162 1 <br /> Madison,W 153707-7162V <br /> Sanitary permit Applicati®n State Transaction 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 sanitary permit. Note:Application forms for state-owned PO WTS are submitted to Project Address(if different than mailing address)/f <br /> the Department of Safety and Professional Services. Personal information you provide may be used for secondary ?�� L � <br /> oses in accordance with the PrivacyLaw,s.15.04 1 m),Slats. J <br /> L Application Information—please(Print All Information <br /> Property Owner's Name Parcel# © � yo7 02 j `�,26 <br /> Property Owner's Mailing Address Property Location/0 <br /> s d I^e- clG4 L Govt.Lot <br /> City,State Zip Code Phone Number _y4 /, Section <br /> (circle <br /> T�_N; R E on Wl <br /> 11.Type of Building(check all that apply) Lot# <br /> or 2 Family Dwelling-Number of Bedrooms J_�2_ — Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number El Village of � <br /> Mown of 0 <br /> 111.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' ❑ New System 'Replacement System ❑ Treatment/Holding Tank Replacement Only Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of PUNTS 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 /> RFlolding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.IDns ersalPll'reatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o <br /> New Tanks Existing Tanks y o y a <br /> a U cn n [s C7 w <br /> Holding Tank <br /> Dosing Chamber <br /> VIII.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 I 1 J 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 <br /> VIIIII.Count /II➢e artment Use Only <br /> Permit Fee Date Issued 'J Issuing Agent Signature <br /> Approved ❑ Disapproved <br /> $ <br /> ElOwner Given Reason for Denial <br /> IX.Conditions of Approval/Reasons for(Disapproval <br /> APPROVED <br /> Attach to complete plans for the system and i to t e oun on paper not less than 8 1/2 x 11 inches in size <br /> SBD-6398(R0313) <br />