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Y,cxoT-+iH" <br />County <br />Safety and Buildings Division <br />1400 E Washington Ave <br />Sanitary Permit Number (to be filled in by Co.) <br />p <br />P.O. Box 7162 <br />S <br />Madison, WI 53707-7162 <br />Sanitary Permit Application <br />State Transaction Number <br />In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this 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 />I. A plication Information — Please Print All Information <br />Property Owner's Name <br />! <br />Parcel # p ,7 d� <br />y 02 3, <br />Jcel <br />Ccc) Cr d C, C> <br />Property Owner's Mailing Address <br />n <br />Property Location <—/ <br />j� <br />c; 5_6 ;' 1 / i1) G /1A -CC A-), <br />Govt. Lot I <br />L—` y, I� y,, Section <br />City, State <br />Zip Code <br />Phone Number <br />��/4� N /%'J/1✓� • <br />`5 Aa23 <br />-17.0 C> S2TSN_ <br />R /fcirclEo( <br />r <br />II. Type of Building (check all that apply) <br />Lot # <br />Subdivision Name <br />9r 2 Family Dwelling — Number of Bedrooms <br />// <br />Block # <br />❑ Public/Commercial — Describe Use <br />_ <br />❑ City of <br />El State Owned — Describe Use <br />❑ Village of --� <br />Number <br />'W own of /17 e— /J O <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 />El 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 <br />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/Treat ent Area Information: <br />DesignFlow (gpd) <br />Design Soil Application Rate(gpdsf) <br />Dispersal Area Required (sf) <br />Dispersal Area Proposed (sf) <br />System Elevation <br />��©� <br />, 7 <br />y� <br />y5, <br />17, .� <br />VI. Tank Info <br />Capacity in <br />Total <br /># of <br />Manufacturer <br />Gallons <br />Gallons <br />Units <br />New Tanks Existing Tanks <br />o m <br />cn in w 0 <br />a. U V C7 <br />Septic or Heldipg;jauIC <br />Q 0 <br />5Y e) <br />Dosing Chamber% <br />vG<? <br />VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. <br />Plumber's Name (Print) <br />Plum =er'sSttur <br />MP/MPRS Number <br />Business Phone Number <br />WADE RUFSHOLM <br />227691 <br />715-349-7286 <br />Plumber's Address (Street, City, State, Zip Code) <br />PO BOX 514, SIREN, WI 54872 <br />III. Coun /De artment Use Only <br />Approved <br />❑ Disapproved <br />Permit <br />Date Issued <br />Issuing Agent Sign re <br />/Al <br />11Owner Given Reason for Denial <br />`Fee <br />^ <br />$ 3 /,ee` - <br />� - / S - <br />(6� <br />IX. Conditions of Approval/Reasons for Disapproval <br />1 D 0 ECEIVE <br />_ - - - Attach to complete plans for the system and submit to the County only on paper not less than 81/2 x I Ilik <br />Uch� sizl`1PR 12U <br />2017 <br />13URNETT COUNTY <br />