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`tyrARTr/ County <br /> f` t Safety and Buildings Division BURNETT <br /> 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> P.O. Box 7162 -5 <br /> Madison,WI 53707-7162 <br /> - -a3 e0 <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 <br /> unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are Project Address(if different than mailing address) <br /> submitted to the Department of Safety and Professional Services. Personal information you provide may be <br /> used for secondary purposes in accordance with the Privacy Law,s. 15.04(1)(m), Stars. �q <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name / Parcel U Ln 0 l v? :5 y 7 <br /> N <br /> /C­1,(L) to <br /> Property Owner's Ma iling Address \ Property Location <br /> �L t j'E- •ems— t r Govt.Lot <br /> City,State Zrp Code Phone Number �A, 'A,Section <br /> Gffi r e- r /)lry s,S�31 s (circle o <br /> IL Type of Building(check all that apply) Lot N T 7,9 N; R /.f;> Eor <br /> or 2 Family Dwelling-Number of Bedrooms IZI Subdivision Name <br /> Block N K 0 4t;E' ),s <br /> ❑Public/Commercial-Describe Use <br /> --'" ❑ City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of <br /> Town of L&7ci <br /> III. Type of Permit: (Check only one box on tine A. Complete line B if applicable) <br /> A. New System Replacement System <br /> TreatmenUHolding Tank Replacement Only El Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑ Permit Revision <br /> ❑ Change of ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IV. 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 /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> a , .7 <br /> VI. Tank Info Capacity in Total X of Manufacturer <br /> Gallons Gallons Units o <br /> New Tanks Existing Tanks ;= �, 7 a 2 <br /> Septic or floldivAwTauk- U 60 .� <br /> Dosing Chamber <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Prin t) Plumber's Signa tur MP/MPRS Number Business Phone Number <br /> WADE RUFSHOLM ?-1 227691 715-349-7286 <br /> �Gtc <br /> Plumber's Address(Street , City,State,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 <br /> VIU. County/Department Use Only <br /> Approved ❑ Disapproved Permit Fee Date Issued Iss n A gnature <br /> ❑ Owner Given Reason for Denial <br /> IX. Conditions of Approval/Reasons for Disapproval M <br /> ECE� <br /> APR 13 2015 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 lit x 11 inches m sae <br /> BURNETT COUNTY <br /> SBD-6398(R03/14) ZONING <br />