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y Counry <br /> Safety and Buildings Division q/ N L <br /> 1400 E Washington Ave Sunimy l'crmit Number(to he filled in by Co.) <br /> P.O. Box 7162 <br /> Madison,W153707-7162 S(o6 gZy <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SE'S 383.21(2),Wis.Arm,Cad,submission taithis form w the appropriate gm,ernmemal unit -- <br /> 6required prior toobmimngasamudypermit Nae:Application forms for sure-awned POWIN are submitted to Project Address(l'Jiif-crif than mailing address) <br /> the Department of Safety and Professional Ser,ices. Personal information you provide may be used for secondary <br /> u s in accordance with the Privac law,s. 15.04 1 m Sure <br /> I. Application information-Please Print All Information <br /> Property Owner's Name Parcel a O '7 O/ 3, <br /> TS <br /> L yYrK rrs eq� s /s /a 5,5_0 00 <br /> Pro�p/erty Owner's Meiling Address Property Location <br /> 07C'J Gmr.Int— <br /> City,Smte Zip Code Phone Number g _y., Section_L <br /> '5R+g1 rn� ssri6 7/3-�s� 3c�� — d.pne <br /> 'f�J N: R /�r EeEWW� <br /> 11.Type of Building(check ell that apply) Lor M <br /> Subdivision Nano: <br /> Ot ort Family Dwelling— m <br /> lin8-Number of Bedrooms � —`— Block kI 0 <br /> p-L' � 0 L4:! I-, r <br /> 0 Public/Commcrcial-Desenbc Use ❑City of <br /> [IStam Owned-Desenbu Use CSM Number ❑ Village of <br /> awn of <br /> _LAGK s a n1 <br /> III.Type of Permit: (Check only one boa on line A. Complete line B if applicable) <br /> A' C] New System lieplacerm nt System ❑l'mmmcnVl luming'1'mtk Rcplaecme'm Only 0 Giller Mudificvtion to[Net ing.Tystcm(explain) <br /> B. El Permit Renewal O Permit Revision OChungeofl'lumber ❑Permit -nn'ram New I,tst Previous Permit Number and Dme Issued <br /> Before Fxpiratim I I Owner <br /> IV.Type of POINTS S stem/Com onent/Device: Check ell that apply) <br /> Pon-PressuduA In-Ground O lhrssurirad In-Ground 0 At-Grnde 0 Mound>24 in.ofsuitahle soil 0 Mound<24 in,ofsuitable soil <br /> OHoldingl'eN 00mer Dispersal Component(explain) O Pretreatment Device,(explain) <br /> V.Dis ersaffreatment Area Information: <br /> Desi Flow(gpJ) Design Soil APPlirarion Imte(gpJsq Dispersal Area RequimJ(s0 Dispersal Acca Proposed(sB System Elevation <br /> I lef.z9 5- <br /> Vt. <br /> Vt.Tank Info Capacity in 'ford I aof Manufacturer <br /> Gallons Gallons lJnilcD v U <br /> NewlW <br /> ' e 8upio8'ran" U y <br /> ci v, M V d <br /> Septi.or llmldine Tank 7S� 7�'0 / 60 <br /> Dpvnen:emter 7J O 1 Iso / G —se' <br /> VII.Responsibility Statement- 1,the undersigned,assumr mspamibility,far Imtellntion of the POW 1SSeh.xr an the attached plans. <br /> Plumber's Name(Prior) Plmnber's SignamrcMI'/MI'RS Number Business Phone Number <br /> WADG RUFSHOLM /J 221691 ]IS-349-]286 <br /> Plumber's Address(Street,City,State,Zip Cade) (/ <br /> PO BOX 514,SIREN,WI 54872 <br /> VIII.County/De urtment Use Only <br /> Affected 11Dimppmsed Permit Fcc Datc Issued Issuing Agent Signature <br /> S ZZf 70 <br /> ❑Owner Given Reasun for Denial <br /> IK Conditions of ApprovaVReasons for Disapproval () D <br /> ,viKfr 8E ar tcsr>' s—o' Fc49.1 InL�l1-. <br /> MAY 2 2 1014 <br /> Attach N Marine plam far the system and shooit to rhe Couoro only on paper oot tau throat \fT� <br /> 7eN1n,G ��f T <br />