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._" <br /> Safety and Buildings Division ,eq riot: 4e...7114:- <br /> 1400 <br /> 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> ., .H. P.O.Box 7162 5 A-0-.21) <br /> Madison,WI 53707-716 ✓ <br /> State Transaction Number <br /> Sanitary Permit Application 623445In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate govermnental unit <br /> is required prior to obtaining a sanitary permit. Note:Application forms for state-owned POWTS are submitted to Project Address(if differeqt than mailing address) <br /> the Department of Safety and Professional Services. Personal information you provide may be used for secondaryIt 1434!// <br /> �43(' <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. <br /> JL Application Information-Please Print All Information ,2 Y7/3 &--yeilhati f I L)e r <br /> Property Owner's Name Parcel# <br /> G 4_9.e./0 Oke") 5- /5 .S 8o e 37.00e) <br /> Property-Owner's Mailing AddressProperty Location <br /> e s / <br /> //0.;,_ R f fJ e rsi side /)n <br /> rAJ Govt.Lot <br /> City,State Zip Code Phone Number y, %, Section <br /> uCfl s e N A.-7- 5-4/6/6 , (circle one <br /> ;. �/pe of Building(check all that apply) Lot# TC5 N; R E W <br /> T <br /> Aor 2 Family Dwelling-Number of Bedrooms ag C7 Subdivision Name <br /> Block# Ph-rer1 a/t°S <br /> „40 <br /> / cJ e(' !/Niece <br /> - Public/Commercial-Describe Use <br /> --.. ❑City of <br /> State Owned-Describe Use `�_ CSM Number ❑Village of h <br /> •-'--- %Town of 0 /4 K f,4A)r <br /> f•Type of Permit: (Check only one host on line A. Complete line B if applicable) <br /> A. i ;-, <br /> i L New System gReplacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> g ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> 13 1 0 Permit Renewal ❑Permit Revision ❑ Change of Plumber <br /> Before Expiration Owner <br /> W.Type of POWTS System/Con ponentPevice: (Check all that amply) <br /> V1�lon-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> 0 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 /> �� 7 C% 3 G/ �� 9.4 ✓ <br /> Vii.Tank Info 1 Capacity in Total #of Manufacturer <br /> i Gallons Gallons Units .fl v o <br /> JNew Tanks I Existing Tanks 5 [ o L 2 <br /> 0 <br /> Septic or Neel fTr'Ak /e n /©Oct / rOcy(‘-‘,(3a----1 cc <br /> Dosing Chamber <br /> II.Responsibility Statement-.l,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber'. Signe MP/MPRS Number Business Phone Number <br /> JADE RUFSHOLM 227691 715-349-7286 <br /> T�— <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 <br /> VIII.County/IBepartment Use Only <br /> proved ❑Disapproved Permit Fee DateJ�ue suing Ag t Signature j <br /> / <br /> i 1 ©Owner Given Reason for Denial / <br /> Ilin.Conditions of Approval/Reasons for Disapproval <br /> TE <br /> !u Die.zaitis vww0 be 'cud tl 3" irew� °`'4 170.04 w'4. 1r d <br /> o£xiSiiv►8 5405401.44,' •b ut a4wNls <br /> . Ktd/ per 515.383. <br /> 1 <br /> w MAY 2 1 2020 <br /> T 3t;,reue�ll e+vrwrs svac�. rwl►o ' a► �o /WIS. _ <br /> Attach t complete plans for the system and submit to the County only on paper not less than 8 1/2 x 1 . ch n size <br /> :LIMO •unty <br /> SBD-6398(R0313) Land Services Department <br /> a� i5252 # a5. <br />