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1 artjft,• County <br /> °• , Safety and Buildings Division b�''t;y/-/t) <br /> 1400 E Washington Ave <br /> g Sanitary Permit Number(to be filled in by Co.) <br /> \ P ,. P.O.Box 7162 1:11•1-.2!)-_2 <br /> Madison, <br /> Madison,WI 53707-7162 <br /> CST-e,-0-2,i <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 (0����9 <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 Services. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. / 0 <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name 1 Parcel# 7 0/6 7 .37/ 7/6 <br /> K z,i coo o///ov <br /> /1 <br /> Property Owner's Mailing Address Property Location �/ //(,..00 <br /> Property <br /> 27C,1 .5"-- o/c ..35 Govt.Lot /°' <br /> City,State Zip Code Phone Number Id, Section /5 <br /> t) e--6 54r bk.)-7 6-<7913 3 7 ,�-3'6C� (circle one) <br /> T 3/ N; R /7 Eor V <br /> II.Type of Building(check all that apply) Lot# <br /> 11-er 2 Family Dwelling-Number of Bedrooms ,------ Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use / ❑ City of <br /> CSM Number ❑ Village of '__...-^ <br /> ❑State Owned-Describe Use / / / <br /> VTown of L- //t1 L e"//1-1 <br /> III(.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. 94Iew System ❑ Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to ExistingSystem(explain) <br /> B. 0 Permit Renewal 0 Permit Revision ❑ Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> 1 Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> Y1-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) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> �o , 7 may y3e) 76, V <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units ,n o o b, <br /> oNew Tanks Existing Tanks 2 - m <br /> a. U m ,,, m w C a, <br /> Septic or Molding-T.nnk /9 7 /evio / /,�v J c rif _...s f_cp 4 <br /> 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 /= jG / y 227691 715-349-7286 <br /> �/t! Xe--- <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 Permit Fee 00 Dat/50,121)21)ssueng gent Signa e <br /> ❑ Owner Given Reason for Denial ✓i• 3 IIX.Conditions of Approval/Reasons for Disapproval #01....< <br /> 'S <br /> # I K�!'c��t l Ire /cvc(� Lot& I� of tier. D <br /> k ,sys Elcvearis s use 6c of or a�liovt 94.90/ - AR A 2020 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x inc in <br /> SBD-6398(R0313) urnett County <br /> Land Services Department <br />