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County <br /> ...r•. Safety and Buildings Division 4-) tiP id <br /> i, 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> P.O. Box 7162 51141.1- 020-02 i=2- <br /> Madison,WI 53707-7162 <br /> State Transaction Number Ls i 4119 <br /> Sanitary Permit Applicatio, 1 <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 Project Address(if different than mailing address) <br /> the Department of Safety and Professional Services. Personal information you provide may be used for secondary ,:•7 85,3- <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. <br /> I. Application Information-Please Print All Information 3 /12/Ve, A60/ <br /> Property Owner's Name Parcel# (9 7 0/2 a <br /> 5-84+id Jii-rt)5 e--/J .5-- ;.5- .F.5-F o9/00.0 <br /> Property Owner's Mailing Address....zd Property Location <br /> 3 9O / "' A-ve., Aj - Govt.Lot <br /> City,State Zip Code Phone Number 1/4, <br /> 1/4, Section ,;...e..3 <br /> 11,1-m L, ke- MA) S -5 -7c) 4/ 661 ,,19F ;75& ' circle 0. <br /> T 96 N; R 451' E6 <br /> II.Type of wilding(check all that apply) Lot# <br /> 1 P!(4 or 2 Family Dwelling-Number of Bedrooms 3 F V Subdivision Name <br /> Block# 4 1 <br /> a)iefarild 04,/,,, v v <br /> 0 Public/Commercial-Describe Use ____ -- ....-- <br /> 0 City of _ <br /> ---- <br /> 0 State Owned-Describe Use --- CSM Number 0 Village of <br /> •----. <br /> ' Town of SA-c-k S el"3 <br /> MI.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. 0 New System ;i(Replacement System 0 Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> 1 <br /> B. 0 Permit Renewal El Permit Revision 0 Change of Plumber 0 Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> 'ion-Pressurized In-Ground 0 Pressurized In-Ground 0 At-Grade 0 Mound>24 in.of suitable soil 0 Mound<24 in.of suitable soil <br /> 0 Holding Tank 0 Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(at) Dispersal Area Proposed(sf) System Elevation <br /> 9s-e , 7 g 93 es-0 95- <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units <br /> New Tanks Existing Tanks ,, (-3 o -...,' 73 bit "g1 <br /> 0 g 2 2 <br /> ti. C..) iii V, rn 4, 0 0., <br /> Septic or geLaies-Tank A)a 0 .Meti/ I <br /> DosingChamberChamber <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature,4_4(..2.,--; 0. MP/MPRS Number Business Phone Number <br /> WADE RUFSHOLM 227691 715-349-7286 <br /> (....)c.A.4... 4 -..-7//,--.... <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 <br /> VIII.County/Department Use Only <br /> roved 0 Disapproved Permit Fee Date Issued Issuing Agent Signature LATYp <br /> 0 Owner Given Reason for Denial $ '--- 1/'--7-7-0 J. ilif <br /> IX.Conditions of Approval/Reasons for Irisapproval <br /> 1-Keik 15'11,1. <br /> EC L7 :7:L: <br /> . / <br /> &( 1 e A cx t-i n. 43 /2 t5 54I <br /> Attach to complete plans for the system anubmit to the County only on paper not less than I /2 xinc NIte.stz <br /> UV e0 2 2020 <br /> itir #77 113e--1---- <br /> SBD-6398(R0313) - <br /> BURNETT '-rt.INTY <br /> ZON,i.::.A <br />