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Attach to complete plans for the system and submit to the County only on paper not less than 8 In z �nj'sMY 16 2018 II )BUMRNETT COUNTYV <br />Buildings Division <br />County <br />64 r e— <br />Safety and <br />"qj <br />1400 E Washington Ave <br />Sanitary Permit Number (to be filled in by Co-) <br />P.O. Box 7162 <br />(� <br />Madison, WI 53707-7162 <br />Sanitary Permit .Application <br />State Transaction Number <br />In accordance with SPS 38321(2), Wis- Adm. Code, submission of this form to the appropriate governmental unit <br />/v' 14 1 <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 />rl9x ¢ <br />purposes in accordance with the Privacy Law, s. 15.04(I)(m), Stats. <br />as/9o� <br />1. Application Information — Please )Print All IInformation <br />Property Owner's Name <br />Parcel # 07 051j -2- <br />C (o <br />J_/, i o-3 o 00 C`r /v2 ®Oo <br />Property Owner's Mailing Address <br />Property Location e / <br />r,Z 7 y 9 s ; r; (Z iej <br />Govt Lot <br />SW �/� /0 '/., Section 3 <br />City, State <br />Zip' <br />Phone Number <br />4 4lu b q l' GcJ -� <br />Code <br />� 7 5,n <br />/ <br />5% o�4/0 7 7 <br />TN R 17 (arch °11W <br />H. Type of Building (check all that apply) <br />Lot# <br />Subdivision Name <br />Mor 2 Family Dwelling - Number of Bedrooms <br />Block # � <br />11Public/Commercial - Describe Use <br />❑ City of '— <br />❑ State Owned - Describe Use <br />❑ Village of <br />CSM Number <br />'$ Town of O/VO /L) <br />IIIII. Type of Permit: (Check only one box on line A. Complete line B if applicable) <br />A. <br />❑ New System <br />Placement System <br />❑ Treatment/Holding Tank Replacement Only <br />❑ Other Modification to Emsting 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 of POWTS System/Component/Device: Check all that a 1 <br />�KN n 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) <br />Design Soil Application Rate(gpdsf) <br />Dispersal Area Required (st) <br />Dispersal Area Proposed (sf) <br />System Elevation <br />y5 d <br />V1. Tank Info <br />Capacity in <br />Total <br /># of Manufacturer <br />Gallons <br />Gallons <br />Units J, U <br />New Tanks Existing Tanks <br />o <br />w U on w vJ is. 0 P. <br />Septic or Holding Tank <br />!� O 1-5-0 <br />C <br />75-x, <br />D ,)e, b y e S. 0 G �— <br />Dosing Chamber <br />VIIII. Responsibility Statement- $, 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 />227691 <br />715-349-7286 <br />Plumber's Address (Street, City, State, Zip Code) <br />PO BOX 514, SIREN, WI 54872 <br />VM. Coun /De artment Use Only <br />Approved <br />I ❑Disapproved <br />Permit Fee <br />Date Issued <br />Issuing Agent Sign <br />❑ Owner Given Reason for Denial <br />3/ tODs")6 <br />/ <br />-1 � <br />Jk <br />IX. Conditions of Approv21VRe2sons for Disapproval <br />D ECEWE <br />Attach to complete plans for the system and submit to the County only on paper not less than 8 In z �nj'sMY 16 2018 II )BUMRNETT COUNTYV <br />