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-` <br />Safety and Buildings Division <br />County <br />r <br />Sanitary Permit Number (to be filled in by Co.) <br />u ' <br />us <br />1400 E Washington Ave <br />P.O. Box7162 <br />sw -19-16 <br />Madison, WI 53707-7162 <br />Sanitary Permit Application <br />State Transaction Number <br />�3 Sv <br />In accordance with SPS 383.21(2), Wis. Adm. Code, submission of thus form to the appropriate governmental unit <br />Project Address (if different than mailing address) <br />is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are submitted to <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 />C, <br />37 <br />Parcel d 7 (}dt 5/6 / V c/ <br />I. Application Information - Please Print All Information <br />Property Owner's Name <br />„� <br />C7:-� <br />el Cal •'A 0 0OD <br />Property wner's Mailing Address <br />Property Location ,0 e_ I <br />G ez) C 1 /0 <br />Govt. Lot <br />y4 1 , Section <br />City, State <br />Zip Code Phone <br />Number <br />(e �! / G cc %✓� <br />/ <br />J o� <br />`�- <br />�`✓ � <br />(circle one <br />� T� N; REtV <br />II. Type of Building (check all that apply) Lot <br /># <br />Subdivision Name <br />El or 2 Family Dwelling -Number of Bedrooms <br />3 <br /># <br />Block <br />-� <br />❑ City of <br />❑ Public/Commercial - Describe Use <br />" - CSM <br />❑ State Owned -Describe Use <br />❑ Village of <br />'Town of -5 <br />Number <br />V / A / ,;2 % <br />III. 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 />B. <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 stem/Com onent/Device: Check all that apply) <br />❑ Non -Pressurized In -Ground ❑ Pressurized In -Ground ❑ At -Grade 0-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/Treat ent Area Information: <br />Design Flow (gpd) <br />Design Soil Application Rate(gpdsf) <br />Dispersal Area Required (sf) <br />Dispersal Area Proposed (sf) <br />System Elevation <br />Y5_0 <br />l <br />s-d <br />Z71 5 <br />ys. s— <br />VI. Tank Info <br />Capacity in <br />Total <br /># of <br />Manufacturer <br />. <br />b <br />Gallons <br />Gallons <br />Units <br />tC U <br />o v <br />U U <br />aj y <br />rn <br />New Tanks <br />Existing Tanks <br />H o <br />a U <br />v, ti <br />i <br />n <br />s c7 <br />a <br />Septic or I3elding.Tank <br />Dosing Chamber <br />VII. Responsibility Statement- 1, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. <br />Plumber's Name (Print) Plumber's Sigliature MP/MPRS Number Business Phone Number <br />L�-- 227691 715-349-7286 <br />WADE RUFSHOLM �- <br />GGG��� fff <br />Plumber's Address (Street, City, State, Zip Code) <br />PO BOX 514, SIREN, WI 54872 <br />VIIY. Coon /De artment Use Only <br />Approved <br />El Disapproved <br />Permit Fee <br />Date Issued <br />Lyssngge Signature <br />❑ Owner Given Reason for Denial <br />J <br />IX. Conditions of Approval/Reasons for Disapproval <br />Attacn to compete pans ,or uIc sysacn. .... ........ • •... ..•, ,,� - <br />SBD-6398 (R0313) <br />�%gliq <br />