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Safety and Buildings Division <br />county <br />da, <br />1400 E Washington Ave <br />Sanitary Permit Number (to be filled in by Co.) <br />P.O. Box 7162 <br />5A W -('6-U-3 <br />Madison, WI 53707-7162 <br />Cao <br />INmac/ <br />Sanitary Permit Application <br />State Transaction Number <br />In accordance with SPS 38321(2), Wis. Adm. Code, submission of this form to the appropriate governmental unit <br />is to a sanitary Note: Application forms for state-owned POWTS are submitted to <br />Project Address (if different than mailing address) <br />required prior obtaining permit <br />the Department of Safety and Professional Services. Personal information you provide may be used for secondary <br />7,2 ;:2- 3 <br />purposes in accordance with the Privacy Law, s. 15.04{1)(m), Stats. <br />N' �} �� L <br />Parcel # <br />a 3 � t _ 1�/- <br />L Application Information - Tease Print All Information <br />Property Owner's Name <br />07- <br />7000 <br />7 ho r�-r S� <br />o S 60,1 - 0 / <br />Property Owner's Mailing( Address <br />Property Location Pe, <br />f L I <br />r � <br />Govt Lot <br />7V <br />y, '/4, Section <br />City, State <br />Zip/Code <br />Phone Number <br />, r <br />�! Sl�l9 <br />Ie one <br />T _� N; R E o V�J <br />H. Type of Building (check all that apply) <br />Lot # <br />Subdivision Name <br />I or 2 Family Dwelling -Number of Bedrooms <br />Block # <br />`�- <br />❑ City of <br />❑ Public/Commercial - Describe Use <br />❑ State Owned - Describe Use <br />❑ village of �— <br />Town of �44 <5 4,J/.55 <br />CSM Number <br />II][. 'Type of Permit: (Check only one box on line A. Complete line )3 if applicable) <br />A. <br />❑ New System <br />❑Replacement System <br />ElTreat%ent/Holding Tank Replacement Only <br />O11 ther Modification to Existing System (explain) <br />( <br />1Bhist <br />❑ Permit Renewal <br />❑Permit Revision <br />❑Change of Plumber <br />❑Permit Transfer to New <br />Previous Permit Number and Date Issued <br />Before Expiration <br />Owner <br />IV. Tyee <br />of POWTS S stern/Com onent/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 />❑ 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)Dispersal <br />-7 <br />Area Required (st) <br />Dispersal roposed (sf) <br />System Elevation <br />5--� <br />, <br />e�l, y3 <br />�?/ <br />V1. Tank Info <br />Capacity in Total # of Manufacturer <br />Gallons Gallons Units -0 ;; U <br />New Tanks L•)dsting Tanks o y L s <br />a V 65 an is. C7 P <br />Septic or Hcktftt-g-Mk <br />Q v D v O /^ e S"G I=) <br />Dosing Chamber <br />V11. 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 />MPMIPRS Number <br />Business Phone Number <br />WADE RUFSHOLM <br />/ , / _ D <br />227691 <br />715 349-7286 <br />Plumber's Address (Street, City, State, Zip Code)�Gtc— <br />PO BOX 514, SIREN, WI 54872 <br />VIII. Conn /De artment Use Only <br />❑ Approved <br />Disapproved <br />Permit Fee <br />Daae Issued <br />Iss ' g Agent Si <br />❑ Owner Given Reason for Denial <br />Ix. Conditions of Approval/Reasons for Disapproval 1C--" <br />/T b,-1�.��� -�'or e,��w <br />�� ���'���r• 5,1.5+G1,�5 40 <br />R7 <br />Attach to complete plans for the system and submit to We t-ounty only on paper not rens man 0 ALA z Ax Hneuea ul U U 1 -4 1 1 L--/ <br />