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County Safety and Buildings Division ,B(-,{(—it) e <br /> . <br /> it- <br /> `, 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> y Madison,WI 53707-7162 ,.Q _ zl/o <br /> 041?6 Cc/ <br /> ; C5-C- 2 2 -I k? 1 <br /> J4 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 Professional Servies. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. ? q <br /> d 1. Application Information—Please Print All Information ; / /1 /fde,ri/A C--iri <br /> Property Owner' Name Parcel# 7'7 e j ,2 4/ /6 <br /> Property Owner's Mailing Address Property Location <br /> 4 3 65 /M C& , V Govt.Lot <br /> City S to I Zip Code Phone Number 5 er 14, J , <br /> _ / p /Ll�✓ /4, Section 3C <br /> /p- e 6'J/- 767-5 65 7 c// `(circle one <br /> jcU /4 e Grov e_ i- i T // N; R it, E o <br /> IL Typof Building(check all that apply) Lot# <br /> or 2 Family Dwelling—Number of Bedrooms �""' Subdivision Name <br /> _ Block# <br /> L.i Public/Commercial—Describe Use �i ❑ City of <br /> �-..----- CSM Number ❑ Village of "-.- <br /> ❑State Owned—Describe Use 0 <br /> Town of Si:,t)/5-5 <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> ri 1•tew System ❑ Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> { <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> I <br /> .Ion-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) I Design Soil Application Rate(gpdsf) Dispersal Area Required(se Dispersal Area Proposed(st) System Elevation <br /> I <br /> VI.Tank Info I Capacity in Total #of Manufacturer I <br /> Gallons Gallons Units d <br /> Ii- <br /> iNew Tanks Existing Tanks s._gi U 5 2f� n vo w 3E <br /> Septic or tioi 1: k `/lJ -S / Ccv/ _s e.c- -- <br /> Dosing Chamber <br /> 1 I <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 MP/MPRS Number Business Phone Number <br /> WADE RUFSHOLM ' �J, /(��{/e--- 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) (� <br /> PO BOX 514,SIREN,WI 54872 <br /> VIII.County/Department Use Only <br /> (A p p r o v e d ! ❑ Disapproved Permit Feeocp Date Issuued I ui g A nt Sign <br /> I ❑Owner Given Reason for Denial l?/• 1/0( <br /> IX.Conditions of Approval/ReasonsL,fo�r Disapproval '/ lei 5-4e� <br /> L VO i t it /ti.45+ & 0.bove— 17 LI (*��c�Qlat'l g/C1ks hj 10 <br /> O rd, ,CC IEBVE, <br /> ' -0 <br /> tee - all Sc c c . <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2' 11 i ices AUGi 2 9 2022 <br /> .. <br /> Burnett <br /> SBD-6398(R. 1 i/11) Land Services Department <br />