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r'u County .�j <br /> Safety and Buildings Division ,(rAt e— / <br /> 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> P.O. Box7162 <br /> Madison,WI 53707-7162 <br /> Sanitary Pen it Application State Transaction Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit &;tD41 <br /> is required prior to obtaining a sanitary permit. Note:Application forms for state-owned POWTS are submitted to Project Address(if different than mailing address) <br /> the Department of Safety and Professional Services. Personal information you provide may be used for secondary 1 �C <br /> purposes in accordance with the PrivacyLaw,s.15.04 1 `;m,Stats. �, ,L J <br /> 1. Allpfication Information-Please Print All Information _ <br /> Property Owner's Name Parcel# O ' 0/,2, „2 J Gz S <br /> Property Owner's Mailing Address Property Location 0, <br /> 1 v e c e e-k Jl e Govt.Lot 1 ' <br /> City,State Zip Code Phone Number '14, %4, Section <br /> 1 <br /> (circle one) <br /> �10 l ^ )4 ,. ?y� _/,� <br /> Z Type of Buffling(check all that a/pppRy) J Lot# T u-N; R %`� E or <br /> / or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> I Block# <br /> ❑Public/Conunercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of <br /> O�T..of ,f'�- -{'CSdA-) <br /> IIII.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑ New System Re lacement System <br /> y � p y ❑ Treatment/Holding Tank Replacement Only El 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 /> TV.Type of POWTS System/Component/Device: (Check all that ap <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(so Dispersal Area Proposed(sf) System Elevation <br /> c5 t� 7 Y3 <br /> VL Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units -fl P; o <br /> New Tanks Existing Tanks c i 5 <br /> Septic or Holding Tank SYL�v 76 / <br /> 22 6 /pQ � c 74— <br /> Chamber Dosin lJs� / <br /> Dosing Chamber >S 0c) I / I C'-J G <br /> VH.Responsibility Statement- 11,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) W <br /> PO BOX 514,SIREN,WI 54872 <br /> V111.Coun /➢fie artrrlent Use Only <br /> pproved ❑ Disapproved Permit Fee Date ssued ss <br /> ° uin Agent si pature <br /> 0111- <br /> ❑ Owner Given Reason for Denial <br /> 3�5 9 3o aoi ► <br /> IZX.Conditions of Approval/Reasons for Disapproval O �.]� <br /> E E V <br /> rLEE <br /> ' APPROVED <br /> l� <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/n;;; <br /> SBD-6398(R0313) y <br /> artment <br />