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�yiFYANYIl5b7 County <br /> Safety and Buildings Division QN/ nle. <br /> t $ 1400 E Washington Ave Sanitary,Permit Number(to be filled in by Co.) <br /> �a P S 1 P.O. Box 7162 3�&W <br /> Madison,WI 53707-7162 <br /> Sanitary Permit Application 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 Project Address(if different than mailing address) <br /> the Department of Safety and Profqsigas Servi qs. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privac Law,s.F15.04(1)(m),Slats. �h o/ly/Q- AdI. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# 6 '7 O a 3 77 1 <br /> I <br /> Q r/,.kS .J / 0 3 Sao %000 <br /> PropertyOwner's Mailing Address Property Location f <br /> / ` ci <br /> / 915_ Q/ 3 5' Govt.Lot <br /> City,state Zip Code Phone Number 510 %,. Section <br /> Gr1�65 �r T.v;r— 866- -3T 3 r�N; R�e one <br /> II.Type of Building(check all that apply) Lot# <br /> St'l or 2 Family Dwelling-Number of Bedrooms 3 Subdivision Name <br /> _- Block# _ <br /> ❑Public/Commercial-Describe Use <br /> ,I El city of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of <br /> 9 Town of /—""j C N <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. )&New System ❑ Replacement System ❑Trcatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> ) <br /> ❑Change of Plumber List Previous Permit Number and Date Issued <br /> B. El Permit Renewal 11 Permit Revision b ❑Permit Transfer to New <br /> Before Expiration ll i ! I'Ii Owner <br /> IV.Type of POWTS System/Component/Device: Check all that apply) <br /> $Non-Pressurized In-Ground ❑Pressurized In-Ground ❑ Al-Grade ❑ Mound>24 in.of suitable soil ❑Mound<24 in,of suitable soil <br /> ❑ Holding Tank ❑(�ther Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdso Dispersal Area Required(so Dispersal Area Proposed(s0 System Elevation <br /> 17 C> 6 Y-7 �7C.- C�6 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o d v <br /> m U <br /> New Tanks Existing Tanks 0 8 <br /> Septic or;4ok4ng-1aok p 00 -__ t)00 <br /> Dosing Chamber <br /> VII.Responsibili Statement- I,the Undersigned,assume responsibility 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.Coun /De artment Use Only <br /> Permit Fee Date Issued Issuing Agent ature <br /> Approved ❑Disapproved d8 $ y` pm _ <br /> `/ ❑Owner Given e'ason for Denial / `t _/ 5 � <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> iEICEIVE <br /> D n <br /> Attach to complete plans for the system and submit to the County only on paper not less thanVa 1 in <br /> 7 <br /> BURNETT CC <br /> �t^a:ste <br />