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County <br /> Safety and Buildings Division ad4lri0 e " <br /> Q S = 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> ' �,, p Madison,WI 53707-7162 •3 -.2, 1—33 <br /> CST- L34.) 1n510 8gg <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 Servies. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. 77a S D/Q'k s <br /> I. Application Information-Please Print All Information / <br /> Property Owner's Name Parcel# 07 032 2 V /6 2 8 s <br /> t <br /> 1--#4 d y` C 44.iA) IS' 74, o/19dOO <br /> Property Owner's Mailing Address Property Location -Tax `D; Z 2 0-12 <br /> 1f0335. Go.)ermtzof Id Z3O1l <br /> Govt.Lot Tax 1 fl v <br /> City,State Zip Code Phone Number �/ ''/, '/, Section �o <br /> i /oic-i ley /flt) 5So37 212 37p 970`! T // N; R '�(circle onel <br /> H.Type of Buileing(check all that apply) Lot# E o��JC <br /> Vyor 2 Family Dwelling-Number of Bedrooms tr:7 6 Subdivision, Name <br /> Block# SUUo11Dit)Gd47 567d <br /> 0 Public/Commercial-Describe Use ❑ City of <br /> ❑State Owned-Describe Use -� CSM Number ❑ Village of —1- <br /> Town of S W ,:s..5 <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. KNew System ❑ Replacement System 0 Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. IIPermit Renewal ❑ Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> KNon-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(sf) Dispersal Area Proposed(sf) System Elevation <br /> 3aa . 7 ,,,l9 5'.5--v 76 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o - o$ <br /> New Tanks Existing Tanks C c a g <br /> i ^ ^y1 / k U -' 3, w C7 Sri.. <br /> Septic or /D40 /t�()D / oY/.21- H`t/� O )I-- <br /> Dosing 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) Plumber's Signature MP/MPRS Number Business Phone Number <br /> WADE RUFSHOLM 'J atplC// 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 <br /> VIII.County/Department Use Only <br /> Approved ❑ Disapproved Permitu Fee�j 'D(a Is u�e/d�(� Issuin Agent Signature <br /> i 0 Owner Given Reason for Denial $ I v v 111 lives I <br /> a� <br /> IX.Conditions of Approval/Reasons for Disapproval �7 --� <br /> i Iti aiA 5.090,c45 v <br /> ,F0,,, ^) (AM MAJI-f'`-( cnd S�u.-k rggr tires rtf'S <br /> iSt�l l S -b be vP,nf►er1 iilI �'t �� 1,�Sec-h MAR U 8 2024 _I <br /> ��� Attach to complete plans"for the system and si. mit to th County only on paper not less than 8 1/2x ITinc as in size <br /> Cl�"Y1b1/l,Ld (A.17 "t C ��� Sur�i`� (0/4) Land <br /> Services Department <br /> - <br /> SBD-6398(R. l 1/11) 11 I IZUGy L42.5 C #)'Q 1 t 3 <br />