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��4axttr <br />,2/`�;� Safety and Buildings Division <br />Co&JyVMfJ'PU I = 16CANNLD <br />BURNETT <br />1400 E Washington Ave <br />}` <br />Sanitary Permit Number (to be filled in by Co.) <br />P.O. Box 7162 <br />Madison, WI 53707-7162 <br />r �7 <br />S <br />Sanitary Permit Application <br />State Transaction Dumber <br />In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental <br />ovh4-1 �P..t &.d <br />Project Address (if different than mailing address) <br />unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are <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. <br />&40,7 f! xe Ayd aj <br />I. Application Information - Please Print All Information <br />Property Owner's Name <br />Parcel # vmc vbf / 1 q 7t7 <br />AIJ� <br />S� �� <br />/J o t Wl s,4701 <br />7_ -z -A-Z-3 01-6W-0Z1kV0 <br />Property Owner's Ma fling Address <br />Property Location <br />_D <br />Govt. Lot <br />'A . _ ) tk,Section 07 <br />�bbL <br />City, State <br />Zip Code <br />Phone Number <br />5 V-973 <br />�/ <br />! / - !�'/ <br />(circle one) <br />T N; R � E or <br />II. Type of Building (check all that apply) <br />Lot # <br />1 or 2 Family Dwelling - Number of Bedrooms 67, <br />Subdivision Name <br />Block # <br />❑ Public/Commercial - Describe Use <br />❑ City of _ <br />❑ State Owned - Describe Use �- <br />❑ Village of <br />CSM Number <br />V-6 P 3 j <br />V, Town of <br />III. <br />Type of Permit: (Check only one box on line A. Complete line <br />B if applicable) <br />A' <br />❑ New System <br />❑ Replacement System <br />,® Treatment/ITank Replacement Only <br />❑ Other Modification to Existing System (explain) <br />B. <br />El Permit Renewal <br />El Permit Revision <br />El Change of <br />El Permit Transfer to New <br />List Previous Permit Number and Date Issued <br />Before Expiration <br />Plumber <br />OwnerI <br />I <br />IV. <br />Type of POWTS System/Component/Device: (Check all that apply) f CO. <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 Dspersal Component (explain) ❑ Pretreatment Device (explain) <br />V. Dispersal/Treatment Area Information: <br />Design Flow (gpd) <br />Design Soil Application Rate(gpdsf) <br />Dispersal Area Required (sf) <br />Dispersal Area Proposed (sf) <br />System Elevation <br />VI. Tank Info <br />Capacity in <br />Total <br /># of <br />Manufacturer <br />Gallons <br />Gallons <br />Units <br />2 <br />o b„ <br />New Tanks <br />Existing Tanks <br />a` U <br />in <br />U� <br />Septic or Holding Tank <br />/ <br />Dosing Chamber <br />7�r © <br />7:5 0-- <br />VII. Responsibility Statement- 1, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. <br />Plumber's Name (Prin t) <br />WADE RUFSHOLM <br />Plumber's Signa ture <br />/ % ,i! <br />MP/MPRS Number <br />227691 <br />Business Phone Number <br />715-349-7286 <br />_ <br />Plumber's Address (Street , City, State, Zip Code) <br />PO BOX 514, SIREN, WI 54872 <br />VIII ount Department Use Only <br />Approved <br />El Disapproved <br />Permit Fee <br />Date Issued <br />Issuing t Signature <br />❑ Owner Given Reason for Denial <br />$ <br />IX. Conditions of Approval/Reasons for Disapproval <br />FEB 23-­3 <br />Attach to complete plans for the system and submit to the Count% only on paper not less than 8 1/2 x 11 inch13UFINM <br />COUNTY <br />SBD -6398 (R03/14) <br />ZONING <br />