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Safety and Buildings Division <br />County <br />,ter 1400 E Washington Ave <br />Sanitary Permit Number (to be filled m by Co_) <br />i'j P.O. Box 7162 <br />FD <br />SAN - /8 - 76 <br />�: ;Ci Madison, WI 53707-7162�7 <br />grfo 4 .% <br />y3Sy <br />G o Q / 7 3 <br />Sanitary permit <br />sem,,/TransacfionNumber <br />.Application <br />/v r/d <br />In accordance with SPS 38321(2), Win. 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 <br />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. 15.04(1)(m), Stats. <br />Lam/ / <br />7 7 <br />arcel #0 <br />7' D3 y- - - 37 -/?" A7 - <br />I. Application Information —Please Print All Information <br />Property Owner's Name <br />S - <br />.S /4 - O to S"- p/SOLO <br />Pmp&ty Owner's Mailing Address <br />Property Location <br />W 3 © vL11 <br />Govt Lot <br />'/, '/., Section 2 Z <br />City, StateZip <br />Code <br />Phone Number <br />, rl <br />��� G <br />(circle ongb, <br />Lot # <br />H. Type of Building (check all that apply) <br />� <br />(1 <br />Sunbdivis-io'n/Name <br />1 or 2 Family Dwelling -Number of Bedrooms <br />(' N if <br />l <br />t!(� 5 PSS CO/� <br />Block <br />d.J OJ V10/1j/A714, <br />❑ Public/Commercial - Describe Use <br />❑ City of <br />11CSM <br />State Owned - Describe Use <br />❑Village of <br />�9 Town of 4 <br />Number <br />DOL Type of Permit- (Check only one box on line A. Complete line B if applicable) <br />A_ <br />❑ New System <br />Replacement System <br />❑ Treatment/Holding Tank Replacement Only <br />❑ Other Modification to Existing System (explain) <br />1B. <br />❑ Permit Renewal <br />❑ Permit Revision <br />❑ Change of Plumber <br />❑ Permit Transfer to New <br />List Previous Permit Number and Date issued <br />Before Expiration <br />Owner <br />IV. Type of POWTS S m/Com onent/Device: Check all that ap l <br />❑ Non -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. Dis ersal/Treatment Area Information: <br />Design Flow (gpd) <br />Design Soil Application Rate(gpdst)Dispersal <br />Area Required (st) <br />Dispersal Area Proposed (s1) <br />System Elevation <br />15 0 <br />-- <br />-- <br />VI. Tank Info <br />Capacity in <br />Total # of Manufacturer <br />Gallons <br />Gallons Units -0 2 0 2 <br />[d U <br />New Tanks Existing Tanks <br />o <br />w U CZ h u) iw C7 P. <br />Sgiwr Holding Tank <br />e <br />Dosing Chamber <br />VH. Responsibility Statement- 1, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. <br />Plumber's Name (Print) <br />Plumber's Signature <br />MP/MPRS Number <br />Business Phone Number <br />WADE RUFSHOLM <br />227691 <br />715-349-7286 <br />Plumber's Address (Street, City, State, Zip Code) <br />PO BOX 514, SIREN, WI 54872 <br />II. Conn /De ar'tment Use Only <br />Approved <br />El Disapproved <br />Permit Fee <br />$ <br />D//ate issuQed <br />Issuing Agent Signature <br />11Owner Given Reason for Denial <br />7s^ <br />�O V <br />IX. Conditions of Approval/Reasons for Disapproval <br />re-�o'„n <br />15 e-r5b . <br />UO V� E <br />D <br />s,*,,u Z ire ��� . <br />Attach to complete plans for the system and submit to the County only on paper not les9 Wan {ep/Z z i� pFpesrn�zelUlU I I �I <br />►u1 'ui BUJRVNI�ETT COUNTYV <br />70MINr <br />