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{?� Safety and Buildings Division <br />Conn <br />u,,ry <br />V 1400 E Washington Ave <br />Sanitary Permit Number (to be filled in by Co.) <br />f= P.O. Box 7162 <br />WI 53707-7162 <br />SAjU—l9—/)3 <br />{ / <br />_ yy <br />Madison, <br />Sanitary permit Application <br />State Transaction Number <br />N, , <br />1n accordance with SPS 38321(2), Wis. Adm. Code, submission of this form to the appropriate governmental unit <br />Note: Application forms for state-owned POWTS are submitted to <br />Project Address (if different than mailnag address) <br />is required prior to obtaining a sanitary permit <br />the Department of Safety and Professional Services. Personal information you provide may be used for secondary/C� <br />purposes in accordance with the Privacy Law, S. 15. 1 m), Stats. <br />f,�_ <br />Parcel # 0 -7 0 6 6, ;13 � / % <br />1. Application Information —)Please Print All Information <br />Property Owner's Name <br />Property Owner's Mailing Address <br />Property Location <br />e� t (.,L�� J �o X <br />Govt Lot <br />Section _ <br />City, State <br />Zip Code <br />Phone Number/'/, <br />f <br />Q (circle one <br />T-3tZTI; REor <br />H. Type of Building (check all that apply) <br />Lot# <br />Subdivision Name <br />1 or 2 Family Dwelling -Number of Bedrooms lj�b <br />"`� <br />Block # <br />❑ City of <br />11Public/Commercial - Describe Use ._ <br />❑ State Owned - Describe Use <br />11 village of w—_ <br />�4`own of <br />CSM Number <br />III. Type of Permit: (Check only one box on line A. Complete line B if applicable) <br />A. <br />New System <br />?(New <br />``` <br />❑ Replacement System <br />❑ Treatment/Holding Tank Replacement Only <br />❑ Other Modification to Existing System (explain) <br />16• <br />El Permit Renewal <br />Permit Revision <br />Change o£Plumber <br />❑ Chan <br />❑Permit Transfer to New <br />List Previous Permit Number and Date Issued <br />Before Expiration <br />Owner <br />IV. Type <br />of POWTS Sys tem/Comonent/Device: Check all that apply) <br />((Non -Pressurized ba -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) <br />Design Soil Application Rate(gpdsf) <br />Dispersal Area Required (sf) <br />Dispersal Area Proposed (st) <br />System Elevations <br />oc <br />VI. Tank Info <br />Capacity in <br />Total# <br />of Manufacturer <br />Gallons <br />Gallons <br />Units S, <br />Rf U <br />() U mvJ <br />New Tanks Existing Tanks <br />o <br />a 0 <br />M <br />C-0 y C") F, <br />m <br />a <br />Septic or <br />G E <br />Dosing Chamber <br />VIIL Responsibility Statement- 1, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. <br />Plumber's Name (Print) <br />WADE RUFSHOLM <br />Plumber's Signature <br />MP/MPRS Number <br />227691 <br />Business Phone Number <br />715-349-7286 <br />Plumber's Address (Street, City, State, Zip Code) <br />PO BOX 514, SIREN, WI 54872 <br />VIII. Coun /De artment Use Only <br />Approved <br />I ❑ Disapproved <br />Permit Fee <br />$ o© <br />Date Issued <br />/ <br />issuing Agent Signature <br />❑ Owner Given Reason for Denial <br />37,5-, <br />IX. Conditions of Approval/Reasons for Disapproval le <br />�T1�6�T*a'1`�c� - <br />/�-e(/1S� <br />�S�d <br />Cara �e •�o✓�vm�►•v <br />9 <br />/i f f RV <br />I EV* <br />to complete plans for tae system ana ruDow to me a,ounry only on paper we Seas umu ..wo ... �.K. <br />JUN 12 2018 IU <br />