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Attach to complete plans for the system and submit to the County only on paper not less tha1/2 P4llhditi(Id <br />SBD -6398 (R0313) AUG <br />lG 1 0 <br />CA <br />2018 <br />= <br />UD <br />BURNETT r^rnl Intro <br />Safety and Buildings Division <br />County <br />,c4 r, < <br />Sanitary Permit Number to be filled in b Co. <br />tars ( yCo.) <br />1400 E Washington Ave <br />�Sp <br />`. S <br />P.O. Box 7162 <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 />is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are submitted to <br />Project Address (if different than mailing address) <br />the Department of Safety and Professional Services. Personal information you provide may be used for secondary <br />c <br />purposes in accordance with the Privacy Law, s. 15.04 1 m , Stats. <br />y �f <br />Y <br />Parcel # O -S % -S <br />I. Application Information—Please Print All Information <br />Property Owner's Name <br />-r K( -y <- <br />c,.,--CC, -O -Rae, <br />m <br />Property Owner's Mailing Add ss <br />J <br />Property Location <br />'—/ <br />T/ Z C:� C C, L I Q I` <br />Govt. Lot <br />/., %<, Section � L <br />State <br />Zip C`ode Phone <br />Number <br />City, <br />ff4��6 I L(.?� <br />/ <br />Jr,7 11 / 'F- L' <br />/ a� ' �6/ y 5 / yT <br />� N; R E or circle one�- <br />II. Type of Building (check all that apply) Lot <br /># <br />51 <br />Subdivision Name <br />111 or 2 Family Dwelling — Number of Bedrooms <br /># <br />Block <br />❑ City of � <br />❑ Public/Commercial — Describe Use <br />' CSM <br />11 State Owned —Describe Use <br />❑ Village of <br />Town of <br />Number <br />"� <br />'� I _) � J q � <br />l <br />111. Type of Permit: (Check only one box on line A. Complete line B if applicable) <br />A. <br />ew System <br />((❑ <br />❑ Replacement 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 />C1 Permit Transfer to New <br />List Previous Permit Number and Date Issued <br />Before Expiration <br />Owner <br />IV. Type <br />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. Dispersal/Treatment Area Information: <br />Design Flow (gpd) Design Soil Applic tion Rate(gpdsf) Dispersal Area Required (so Dispersal Area Proposed (so System Elevation <br />3 -7g I <br />3© v o€ 57 5— <br />VI. Tank Info Capacity in Total # of Manufacturer y [ ° <br />Gallons Gallons Units <br />New Tanks Existing Tanks o g i .2 .9 <br />2 U in y w C7 P, <br />Septic or Hek k* -Tank <br />Sr 4/ v <br />�yv <br />Dosing Chamber <br />56 U <br />J <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 />Plumber's Signature <br />MP/MPRS Number <br />Business Phone Number <br />WADE RUFSHOLM <br />/� <br />164) '�f <br />227691 <br />715-349-7286 <br />Plumber's Address (Street, City, State, Zip Code) <br />PO BOX 514, SIREN, WI 54872 <br />VIII. Coun /De artment Use Only <br />Approved <br />❑ Disapproved <br />Permit Fze'e D <br />$ O <br />Date Issued <br />IssuingIssuing Agent Signature <br />Y, <br />❑Owner Given Reason for Denial <br />37J , <br />�- ! -/O/ <br />IX. Conditions of Approval/Reasons for Disapproval <br />APPROVED <br />I T-- 1 (� <br />Attach to complete plans for the system and submit to the County only on paper not less tha1/2 P4llhditi(Id <br />SBD -6398 (R0313) AUG <br />lG 1 0 <br />CA <br />2018 <br />= <br />UD <br />BURNETT r^rnl Intro <br />