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;,Yae'r;(i.': County <br /> 7 Safety and Buildings Division 4 c/i'/i)e- <br /> 1400 E Washington Ave <br /> � �: Sanitary Permit Number(to be filled in by Co.) <br /> L,"---' , P.O.Box 7162 <br /> `'' . , SIM;2044,nv ,// <br /> Madison,WI 53707-7162 <br /> Sanitary Permit Application <br /> State Transaction Number <br /> iov <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit (023703 <br /> { is required prior to obtaining a sanitary permit. Note:Application forms for state-owned POWTS are submitted to Project Address(if different than mailing address) <br /> { the Department of Safety and Professional Services. Personal information you provide may be used for secondary a .7...5-y <br /> 5-1 <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. <br /> II. Application Information—Please Print All Information .l-h ona�5e7/0 ,L� <br /> Property Owner's Name Parcel# 0 7 c-,/,‘,2 d2 1/e) /. -36 <br /> 4e..verI ..re) 1/ r os' o03 c,aVo606601D <br /> Property Owner's MIling Address Property Location /0<- <br /> 3 c .5-4-;#1,f 119 i//`t'c/ ri-, <br /> Govt.Lot 4-3 <br /> City,State Zip Code Phone Number , 3 C <br /> s✓g ,/q /ti L' /� Section <br /> in/ N.Ve-i,/)Aii- /4/t/ 5_5-30 5 S-C 6" CJ /y71circleone__ <br /> Il.Type of Building(check all that apply) Lot# T 1/41 N; R /' E or 1 <br /> CI or 2 Family Dwelling-Number of Bedrooms 3 /d2 Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use --- <br /> 0 City of <br /> ❑State Owned-Describe Use — CSM Number 0 Village of <br /> Va /J .2O OTownof �01c-&.So"J <br /> I / <br /> ;ilii Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. I ;� <br /> ! .1 New System Replacement System eatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> Py. I ❑ Permit Renewal ❑Permit Revision ❑ Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> IBefore Expiration Owner <br /> P7.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 /> El Holding Tank ❑Other Dispersal Component(eiplain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> l <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> IIII /-5--e? Ag. , 7 , `73 6.5."-e", 7‘i <br /> VAI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units I' o f New Tanks Existing Tanks aao <br /> i A <br /> as O t , m is <br /> V .L1 <br /> Septic orHei enk //0L) deo" 7 Q /7.5-0 .2 /U oe'4:t✓e3..$e_e'-Itvi C p -* <br /> Dosing Chamber **Ch,4� / 4104. i izoC l_ o <br /> VII.Responsibility Statement-gam,the`•undersigned,assume reponsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> WADE RUFSHOLM % 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 <br /> VIII Country/Department Use Only I <br /> trJ/�p,proved ❑ Disapproved Permit Fee Dat Issu1 3115 °C+ 1 Al Aelb p <br /> ssuin: gent�ign e / <br /> ( ❑Owner Given Reason for Denial <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> i c t raF,'m to et+mittkelA to D refs re, oil itt s f� w�w� Meets. _ <br /> 1� pIatPla,u� far -! k ivtcor wtat�ir.., <br /> 4 tc pi�s;b4G o!a 8u44wat/ is is be cased. <br /> r . . . „ „ . 1: <br /> Jounty,Attach to complete plans Tor the system and submit to the County only on paper not less than 8 1/2 x 11 incAii in4 APR 2 1:il......____SBD-6398(R0313) <br /> Burnett:ervice <br /> Pl/1L ,r..n. 474 et§ <br />