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perART�Ey� County <br /> Safety and Buildings Division BURNETT <br /> � ! :I 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> P.O. Box 7162 r <br /> Madison,WI 53707-7162 _-4 <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 <br /> unit is required prior to obtaining a sanitary permit. Note: Application fortes for state-owned POWTS are Project Address(if different than mailing address) <br /> submitted to the Department of Safety and Professional Services. Personal information you provide may be <br /> used for secondary purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. 5_15 <br /> I. Application Information-Please Print All Information <br /> Property Owner's Nam//ee _ Parcel# c5 <br /> R6 6 <br /> Property Owner's Ma iling AddressJ Property Location <br /> / c% Govt.Lot <br /> City,State Zip Code Phone Number I= <br /> 1A,AfA0 k,Section <br /> v (circle o e� <br /> II. Type of U611ding(check all that apply) Lot# T N; R E or <br /> ❑ I or 2 Family Dwelling-Number of Bedrooms -- Subdivision Name <br /> Block# <br /> ❑ Public/Commercial-Describe Use ❑ City of <br /> ❑ CSM Number 11 Village ofState Owned-Describe Use / <br /> 'P�`fown of Cil, <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. �New System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber 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 ❑ 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/ reatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevv on <br /> / /-/-77r,-.> 7 r 0 <br /> VI. Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o Y <br /> New Tanks Existing Tanks <br /> Septic or`tfbidiitg-Tank —7 2 L2C— <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(Priv t) Plumber's Signa ture 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 /> VIII. County/Department Use Only <br /> Permit Fe._ Date Issued Issuing A Signa e <br /> Approved 11 Disapproved 1� <br /> ❑ Owner Given Reason for Denial <br /> IX. Conditions of Approval/Reasons for Disapproval <br /> u�7 I 3L Attach to complete plans for the system and submit to the County only on paper not less than S 112 x 11 inches in size <br /> SBD-63918(803/14) <br />