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errrar -- County <br /> A�w Ft'r4 U/1 <br /> =� Safety and Buildings Division ^,� e <br /> `L 1'y p i; 1400 E Washington Ave Sanitary jit Number to be Sued in by Co.) <br /> P.O. Box 7162 41 a 3 <br /> S ,!zj Madison,WI 53707-7162 <br /> �.� ✓ <br /> �kE33t03::i'� I V <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 38321(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 POINTS 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.M(I)(m),Slats. <br /> I. Application Information-Please Print All Information Property27/ <br /> `'s Name Parcel# O 7o.2 8 o:�/ y� j <br /> o coo 011,200 <br /> Property O er's Mailing A Property Location <br /> 7172 Govt.Lot <br /> City,State or Zip Code Phone Number 7 V�22e y,, won <br /> (circle one <br /> T_ D N; R�E <br /> I.Type of Btli4ding(check all that apply) �J Lot# <br /> Subdivision Name <br /> or 2 Family Dwelling-Number of Bedrooms �" "—� <br /> _ Block <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSMNumber ❑ Village of <br /> )4Town of &e4 9ZAi(l <br /> III.Type 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. ❑ Permit Renewal ❑ Permit Revision El Change of Plumber ❑Permit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: Check all that appi <br /> XNon-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(st) Dispersal Area Proposed(sf) System Elevation <br /> 7 ya �� Z <br /> VI.Tank Info Capacity in Total #of Manufactures <br /> Gallons Gallons Units v <br /> New Tanks Existing Tanks ` <br /> n.U <br /> Septic or Hojdpirf--` C/ c <br /> Dosing Chamber 2—61 <br /> VII.Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name Print Plu b 's Si atur MP/MPRS Number Business Phone Number <br /> WADE RUFSHOLM ) t2C 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 <br /> VIU.Countymepartment Use Only <br /> ❑ Approved ❑Disapproved Permit Fee Date Tssued Issuing Age ature <br /> ❑Owner Given Reason for Denial $ 3 7 S I <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 rrz x 11 inches in size <br />