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.44. ►i County <br /> Jf`' N Safety and Buildings Division Dane <br /> 1:1:).}.. <br /> 4ar D ' ,F.; 201 W.Washington Ave.,P.O.BOX 7162 Sanitary Permit Number(to be tilled`in by Co. <br /> , 1,,,P�1 Madison,Wi 53707-7162 <br /> 13-2015 0o37S <br /> Sanitary Permit Application State Transaction Number <br /> to accordance with St'S 383.21(2),Wis.Mm.Code,submission of this form to the appropriate governmental unit <br /> is required prior to obtaining a sanitary permit. Note:Application(nuns for state-owned POWTS are submitted to Project Address(if different titan mailing address) <br /> the,Department or Safety and Professional Sernies. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy taw,s.15.04(1)(m),Sines. Hwy 12& 18 <br /> I. Application Information-Please Print All Information <br /> Properly Owner's Name Parcel# <br /> Bill &Sheryl Rickerman 0711-321-8530-8 <br /> Property Owner's Mailing Address Property Locution <br /> N11471 State Road 26 Govt.Lot <br /> City,Stale Z)pCode Phone Number NW NE f,Section 32 <br /> Waupun,WI 53963 920-251-1930 (circle one) <br /> II.Type of Building(check all that apply) Lot# T 7 N; R 11 E or 1v <br /> ElIor2 Family Dwelling-Number of Bedrooms 3 2 Subdivision Name <br /> [)lock# . <br /> ❑Public/commercial—Describe Use <br /> ❑City or , <br /> ❑Slate Onmed'-Describe Use CSM Number ❑Village or <br /> 2849 l Town or Cottage Grove <br /> ....:.. ._ .. <br /> Iii Type or Permit (Check only one hox on line A. Complete line B If applicable) <br /> A' ®New System 0 Replacement System 0 Treatment/l lolding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. 0 Permit Renewal ❑Permit Revision ❑Change of Plumber ©Permit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> ]Non-Pressurized In-Ground ❑Pressurized In-Ground !!0 Ai-Grade ❑Mound? <br />