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w.r r -,,)d <br />,,.,•fir%q t <br />Safety and Buildings Division <br />County <br />r DS `, <br />1400 E Washington Ave <br />9 <br />Sanitary Permit Number (to be filled in by Co.) <br />�` P$ w <br />P.O. Box 7162 <br />ri 'F <br />r�FF `r <br />Madison, WI 53707-7162 <br />Sanitary Permit Application <br />State Transaction Number <br />3 / q99,19 <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 />oses in accordance with the Privacy Law, s. 15.04 1 m , Stats. <br />I. Application Information — Please Print All Information <br />Property Owner's Name <br />Parcel # C9' O a 3-/ 'vZ <br />Property Owner's Mailing Address / <br />Property Location 0� / <br />tt52 2J ��1' 7 <br />Govt. Lot <br />114) y, IVf:' y~ Section 9,2 <br />City, State <br />Zip Code <br />Phone Number <br />r A- J i5E�/ C� /� � � <br />J�y� a <br />�j U ��.5 � <br />a circle one) <br />T �O N; R � E o� <br />II. Type of Building (c all that apply) <br />Lot # <br />04 or 2 Family Dwelling — Number of Bedrooms <br />-- <br />Subdivision Name <br />Block # <br />ElPublic/Commercial — Describe Use _ <br />❑ City of �-- <br />❑ State Owned — Describe Use �— <br />❑Village of <br />CSM Number <br />1'-"" <br />ood <br />III. Type <br />of Permit: (Check only one box online A. Complete line B if applicable) <br />A' <br />❑ New System <br />a lacement System <br />❑ Treatment/Holding Tank Replacement Only <br />❑ 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 />OwnerN�/ <br />IV. Type of POWTS System/Component/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. Dis ersal/Treatment Area Information: <br />Design Flow (gpd) <br />Design Soil Application Rate(gpdsf) <br />Dispersal Area Required (s0 <br />Dispersal Area Proposed (sf) System <br />Elevation/ <br />� <br />/s�4 <br />VI. Tank Info <br />Capacity in <br />Total <br /># of <br />Manufacturer <br />o <br />Gallons <br />Gallons <br />Units <br />d <br />L <br />New Tanks Existing Tanks <br />0 <br />a <br />U in ti <br />rn w 0 P, <br />Septic or FIblding-T-mik <br />p <br />�Q� <br />C <br />Dosing Chamber <br />� O ---- <br />�/1� <br />rc­ <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 />PIbe e <br />MP/MPRS Number <br />Business Phone Number <br />WADE RUFSHOLM <br />/� <br />rG <br />227691 <br />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 <br />❑ Disapproved <br />Permit Fee <br />$ <br />Date Issued <br />Issuing Agent Sign e <br />son <br />Owner Given Reason for Denial <br />IX. Conditions of Approva[/Reasons for Disapproval <br />4PPROVEU EEO E0VE <br />Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 Iul x11f1 inr to AUG <br />n 0 2018 1 I 1 f <br />SBD -6398 (80313) IIIIIBURNETT COUNTY <br />ZONING <br />