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�� aaFsi v:• County <br /> Safety and Buildings Division cA r-tiI e, <br /> 1400 E Washington Ave sanitary P�t Number Qto be filled in by Co.) <br /> P.O.Box7162 <br /> Madison,WI 53707-7162Iss <br /> ){1/ <br /> �.2e_YKrt:r4% <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 38321(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 differegt 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 PrivacyLaw,s.15.04 1 m Stats. 9b,9 g 1"1 h/0 6 c f 5 70 <br /> I. Application Information-Please Print All Information d/ <br /> PropertyOwryer's Name Parcel#©-7 00 � %7cZ <br /> Property Owner's Mailing Address ,r�" e_ Property Location <br /> d7/o Ar-1/N a V o%J �l Govt.Lot <br /> City State Zip Code Phone Number <br /> n ! •11 '/., '/,, Section pc-Z <br /> l m/lJ, ? (circle one) <br /> T _ N; R <br /> II.Type of Building(check all that apply) � Lot# �z—E o<D <br /> Yor 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use _ r <br /> ❑City of <br /> f <br /> El State Number ❑Village of State Owned-Describe Use d <br /> U /� �g Town of rT yam' S <br /> III.Type of Permit: (Check only one box on line A. Complete line R if applicable) <br /> A- XNew System ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> ❑ Change of Plumber List Previous Permit Number and Date Issued <br /> B. ❑ Permit Renewal ❑Pemrit Revision g ❑Permit Transfer to New <br /> Before Expiration Owner <br /> TV.Type of POWTS System/Component/Device: Check all that app1 <br /> ❑Non-Pressurized Io-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> r-Zliolding 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 /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units <br /> New Tanks Existing Tanks v d Y <br /> Sep eieer Holding Tank O-/OQ <br /> Dosiag 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 Sigoatur MPIMPRS Number Business Phone Number <br /> WADE RUFSHOLM (p�fj/a�y -i 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 /> Approved ❑Disapproved Permit Fee QDate"Issued Issrrli'ug Agent ign tore <br /> ❑ Owner Given Reason for Denial $ 3-)S U J rO - q <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> nD E nn <br /> �L�fI�L� <br /> Attach to complete plans for the system and submit to the County only on paper not less than 9 112 x 11 htr s' 7 1UJ <br /> SBD 6398(R0313) SURNETT COUNTY <br /> ZONING <br />