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.nru County <br /> � <br /> Safety and Buildings Division <br /> # 1400 E Washington Ave Sanitary Permtt Number(to be filled in by Co.) <br /> '; P.O. Box�� 6VUTERI CAN <br /> y '" Madison,WI 0 . <br /> � y <br /> f��vtoN�� <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental <br /> unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are Project Address(if different than mailing address) <br /> submitted to the Department of Safety and Professional Services. Personal information you provide may be <br /> used for secondary purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. 7 <br /> I. Application Information-Please Print All InformationWP2 W, . <br /> Property Owner's Name Parcel# <br /> off-oar--a-Y0--12-- <br /> ,-,oil SLLL-�G &4�30_5� <br /> Property <br /> (Owwnner's Ma fling Address Property Location <br /> , as / Govt.Lot <br /> C' ,State Zip Code Phone Number �y G!l 1A,Section <br /> ��3 3 !, Ir�,� �-°L (circle o e) <br /> I Type of Buildi check all that apply) Lot# T `-f y N; R E . <br /> Family Dwelling-Number of Bedrooms Subdivision Name <br /> JJ Block# <br /> ❑Public/Commercial-Describe Use ❑ City of <br /> ❑State Owned-Describe Use C`SrM-Number ❑ Village of <br /> *Town of <br /> III. Typy 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. A-Permit Renewal El Permit Revision El change of El Permit Transfer to New List Previous Permit Number and Date Issued <br /> /���/B"```e------fore Expiration Plumber Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that a 1 <br /> ❑ Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ound > 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( <br /> Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> �a is .moo `/',' <br /> VI. Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units a o <br /> New Tanks Existing Tanks c p <br /> a U inn V) W. C7 ci, <br /> Septic or Holding Tank Two <br /> Dosing Chamber W lJ <br /> VII.Responsibility Statement- I,the undersigned,assume responsibilit or installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Prin t) Plumber' 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 /> VI11. Count Department Use Only <br /> 7 proved ❑ Disapproved Permit Fee Date Issued Issuing Agent Si tare <br /> ❑ Owner Given Reason for Denial J V o <br /> IX. Conditions of Approval/Reasons for Disapproval D <br /> OCT # 2013 <br /> Pem�L Rp,o q�A- fo E�Lpl, lahlQ-t I COUNV <br /> Attach to complet plans for the systein and submit to the County only on paper not less than 81 �ONG <br /> SBD-6398(R0313) 1�`1I�' V� <br />