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`,,i•ti s i.,, County <br /> Safety and Buildings Division 0 Ai c=. <br /> ft <br /> u 201 W.Washington Ave., P.O. Box 7162 anitary Permit Number(to be filled in by Co.). <br /> "- •,.,"tea_ Madison,WI 53707-7162 --a1-342 7 r7"1by t9 <br /> '';, -4 <br /> Sanitary Permit Application State Transaction Number <br /> l� In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit <br /> i 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 Servies. Personal information you provide may be used for secondary purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. / /�j 0 p ;_ L n i 5 i J <br /> I. Application Information-Please Print All Information ' `/ <br /> Property 9wner's Name f r .+ *, .� �^ .-�. Parcel# er -7 7 a oz Ve3 J'/3 <br /> C ..Cy/ 7,Jt) e i( 1a.3 00,2 e Boa v 1a,i <br /> PropertyLocation c. <br /> Property Owner's Mailing Address _ /0 <br /> �7 6 r� ./i Govt.Lot 2. <br /> City,State Zip Code Phone Number i y, <br /> VI, Section 3 V <br /> ;,,,Oiler Gr, ,-1 13' /1)10 3-5'07 7 I-V 5 7-5 3yyji(circle one <br /> T V� N; R 0 7 E o> <br /> H.Type of Building(check all that apply) Lot# <br /> i. .r 2 Family Dwelling-Number of Bedrooms 4 f Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use — ❑City of '' <br /> '- CSM Number ❑ Village of <br /> State Owned-Describe Use /r <br /> ❑Town of .SG o.// <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 ❑ Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> i Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> ❑Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> KHolding 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 /> VI.Tank Info Capacity in Total #of Manufacturer 2 <br /> Gallons Gallons Units _, g o 0 <br /> of U U U <br /> New Tanks Existing Tanks y o ;; Y p `ccc <br /> U cn �, v at , u.3 0. <br /> ✓ r Siaror HoldingTank �?Oct� �Odl / l//e_ Se-/ 7- <br /> Dosing Chamber <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumb 's Sign3ture A MP/MPRS Number Business Phone Number <br /> I WADE RUFSHOLM / �-�_ 227691 715-349-7286 <br /> < kW <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 <br /> VIII. .I unty/Department Use Only <br /> 1! Approved ❑ Disapproved <br /> Permit Fee Date Issued Issuin• Al- tSi_ - , <br /> ❑ Owner Given Reason for Denial $3 75-- ii/-1 ( � / <br /> IX.Conditions of Approval/Reasons for Disapproval I ' ee:`; /V F-- I v E <br /> "F3r1 °- OCT 2 8 2021 JI <br /> Attach to complete plans for the system and submit to the County only on paper not less than 1/2 x 1 Lin in size COW <br /> Y <br /> f <br /> -- LAN Semites Departmem <br /> SBD-6398(R. 11/11) <br />