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v'peaart4t�. County -174p <br /> 1� <br /> Safety and Buildings Division ,Ocrr.v 2 <br /> a 1 g 9 Sanitary Permit Number(to be filled in by Co.) <br /> P 1400 E Washington Ave P.O. Box 7162yy <br /> 'o Madison,Wl 63707-7162 <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 unit <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 thePriv I- w,s. I . 4(1)(m),Stats. <br /> L Application Information-Pleai; Print 11 Information _ <br /> Property Owner's Name p Parcel# - <br /> -o 1-7voo <br /> Proerty Owner' ailing Address Property Location <br /> 70V0 Govt.Lot <br /> City,State Zip <br /> CodePhone Number /, .S�,/, Section <br /> e/ <br /> ,(cucle one <br /> Type of Building(check all that apply) '7 Lot# T . l N; R �6 E o <br /> for 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑City of �-- <br /> r-�- CSM Number El village of <br /> El State Owned-'Describe Use -� <br /> V4 I q 1 t 0�� �i rown of /'/'l Le_4 J- 3 <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑New System Kteplacement System ❑TreatmentfHolding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. C1 Permit Renewal El Permit Revision ❑ Change of Plumber El Permit Transfer to New 7 / <br /> Leet Previous Permit Number and Date Issued <br /> Before Expiration Owner /'/1—A9 <br /> IV.Type of POWYS—System/Cam", o eht/ ° vice: Check all that a 1 C <br /> %Non-Pressurized In-Ground 111 f#rcSsu'rizcbl)n-Ground b 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(sf) Dispersal Area Proposed(sf) System Elevation <br /> 34 v .17 ya 5 4/J-a 9� <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units ob <br /> a U <br /> Now Tanks Existing Tanks <br /> a U %n <br /> Septic or Huldiag-Tank [ Qo J'K/�� TT <br /> Dosing Cliamber <br /> VII.ResponsibilityStatement-I,the undersigned,assume responsibility for Installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature `� 227691 S Number Business Phone Number <br /> WADE RUFSHOLMI /'_ ) 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) (/� <br /> PO BOX 514,SIREN,WI 54872 <br /> VIII.County/ eartment Use Only <br /> Permit Fee O Date Issued Issuing Agen ig ture <br /> kApproved ❑ Disapproved <br /> ❑ Owner Given Reason for Denial <br /> IX.Conditions of Approval/Rpilii�ns'for R,y�approval <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 inches in size <br />