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„,,:.,,,\Ri'f-'':...: C011ll[y� <br /> { _ Safety and Buildings Division U f/t' <br /> 1400 E Washington Ave <br /> . '? g Sanitary Permit Number(to be filled in by Co.) <br /> I .. i ,, �'1 P.O.Box 7162 <br /> Madison,WI 53707-7162 <br /> Sanitary Permit Application State Transaction Number <br /> 1 In accordance with SPS 383.21(2),Wis.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 Project Address(if different than mailing address) <br /> 1 the Department of Safety and Professional Services. Personal information you provide may be used for secondary 1 <br /> lJurposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. 7573‘ Lipp L Q(9/t) '3 <br /> I. Application Information–Please Paint All Information <br /> Proeriy Owner's Name Parcel* CJ 7 0,2e) .2 qO/6 7 <br /> ID e.,4/1) Ma5eU5 .5” /5 ©moo a!Vvp <br /> 3,Z(2 <br /> Property Owner's Mailing Address <br /> Property Location <br /> a/32 ,1-317" _St Govt.Lot <br /> City,State Zip Code Phone Number /4, <br /> , <br /> /. Section y <br /> ii C r /k /2//.5 W- 5Y°a 4/ 6/+0‘ 38.7 7�// (circle one <br /> T �/7 N; R /6 E o <br /> IL Type of(Building(check all that apply) Lot# <br /> ' jor 2 Family of Bedrooms / Subdivision�� Name <br /> /3; i elka Le <br /> 7) <br /> Block# <br /> 0 Public/Commercial-Describe Use r, ,_� <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of ` ` <br /> V.7 p /5 6 P1`fown of c,4 lc /5 d <br /> M.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> { f 0 New System 0Replacement System KTreatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> I <br /> i <br /> 1 <br /> B• I 0 Permit Renewal ( ❑Permit Revision 0 Change of Plumber 0 Permit Transfer to New List Previous Permit Number and Date Issued <br /> 1 Before Expiration 1 Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> . Non-Pressurized In-Ground ❑ Pressurized In-Ground 0 At-Grade 0 Mound>24 in.of suitable soil 0 Mound<24 in.of suitable soil <br /> ❑ 'chiding Tank 0 Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(si) Dispersal Area Proposed(sf) System Elevation <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units e, o o <br /> New Tanks Existing Tanks T e t .a <br /> 0 <br /> a.U fn �, co w c7 II is, <br /> Septic or I4okliagTattic /4)D v /D rJ 1 /l `,`mss j r <br /> )c <br /> Dosing Chamber 'D o'1 �.- /To <br /> !/ l�V / v <br /> V <br /> VIII.Responsibility Statement-II,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumb 's Signature MP/MPRS Number Business Phone Number <br /> WADE RUFSHOLM /_ / ' 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 <br /> VIIUII.County/Department Use Only <br /> Permit Fee Date Issued I 1 •ge./Sign • x <br /> f Approved 0 Disapproved /� l <br /> s-1 <br /> 0 Owner Given Reason for Denial $3 7� ) /4'� �& ' / 7I� <br /> IX.Conditions of Approval/Reasons for Disapproval 1// L I�- 1 141 ,b•'3 <br /> (� <br /> !attach to complete plans for the system and submit to the County only on paper not less than 8 L2 a It ' sik!C T - 4 2021 <br /> FIECE [IVE I <br /> SBD-6398(80313) $urnett County <br /> Land Services Department <br />