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i1 .4..otirtr : County <br /> Safety and Buildings Division Ai(Wei( <br /> t" m q;t.„,, '�,� 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> '"'s � .Y. P.O.Box 7162 <br /> .,: Madison,WI 53707-7162 3A13 r ✓54, <br /> Sanitary Permit Application State Transaction Number <br /> Sanitary ll <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit 6923113 <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 <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. — <br /> II. Application Information-Please Print All Information <br /> Pro erty1Owner's Name Parcel# 07 0.3' ,02 y 5 7 /.9/1.Z <br /> ic Lc- L err, jib 0/ oov oil 0©vl 7354'C. <br /> Property Owner'sL/ Mailing Address Property Location <br /> 42/ / et S/aic i, Govt.Lot <br /> City,State ZipCode Phone Number <br /> �C �� /<,�l�l '/<, Section <br /> �f 1- .517/1 i1 -1/5' 6 (circle one <br /> �{ �] IA; T 3 7 N; R�� E V <br /> II.Type of]Building fet`aeck all that apply) Lot 4 <br /> or <br /> 2 Family Dwelling-Number of Bedrooms -- Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use -"- <br /> ❑ City of <br /> 0 CSM Number 0 Village of <br /> State Owned-Describe Use 77-`4,4LAk e <br /> �- Town of <br /> DI.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑New System replacement System 0 Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> 18• ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber List Previous Permit Number and Date Issued <br /> ❑Permit Transfer to New <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> 0 Non-Pressurized In-Ground ❑ Pressurized In-Ground 0 At-Grade Mound>24 in.of suitable soil 0 Mound<24 in.of suitable soil <br /> 0 Holding Tank 0 Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> 111 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 /> 1,5-O. / 4/3-0 ;i_5---c, r 7 w <br /> VI.Tank Info Capacity in Total 4 of Manufacturer <br /> Gallons Gallons Units 2 o ,b 0 <br /> .riNew Tanks Existing Tanks 4 [ V Ti -2 17i <br /> aO Cn tS ce "ix., C.7 0, <br /> Septic or I-I fn c c) _ • <br /> Dosing Chamber d©? i Al X Vl f t-- / <br /> VII.Responsibility Statement- .II,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 /> VIE Connnty/Departnnent Use Only <br /> c&pproved ❑Disapproved PermitrmFee Date I ued ng gent Signa <br /> i 0 Owner Given Reason for Denial $ 41 .DO 57/� <br /> IX.Conditions of Approval/Reasons ffor Disapproval i 1 i. i 1 <br /> , <br /> 1 iti*s fo lot,elctaike t Per SPS. 44 I _t -. s <br /> * phi sh r�cuirtmA Ales K .s4, be w4,ef. 11111 MAY 4 2020 v <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x flinches in size .. ....._.. <br /> .iOUilty <br /> es Department <br /> SBD-6398(R0313) * %SD°a c4 60,31 <br />