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_ Countyp <br /> 3 . tee Safety and Buildings Division 'L �s /'lV e <br /> j 1p.S,P 201 W.Washington Ave.,P.O.Boz (162 Sanitary Pcmrit Number(m be 611cd in by Co.) <br /> Madison,WI 53707-7162 <br /> S1 s66 S7Y <br /> „ .,. <br /> Sanitary Permit Application State Transaction Number <br /> In reamdanm with SPS 383.21(2),W is.Adm.Code,submission of Nis form to Ne appropriate governmental unit <br /> is required prior to obtaining a unitary permit. Note:Application forms for stem-owned POWTS am submitted to Project Address(if different than mailing address) <br /> Ne Department of Safety and Professional Sumies. Pcrson l information you provide may be used I'or secondary r qq9 <br /> u sin accordance with the Privac Lew,s. 15.61 1 m,Stats. 7J O <br /> 1. Application Information—Please Print All Information J <br /> Napery,�ex's Name Pmol X O 7 D/ 04 / O <br /> r /J Lou N L) 6&--3 5 o s 0o3 o z2-000 <br /> Properly Owner's Mailing Address Property Location <br /> yrs- S/Ve A14 Ie Dom, Gn.L fat 3 <br /> ity, <br /> Cate lip Code Throe Number y,,_A, Section �7 <br /> rearm cJooal L, 1 &16 -7 _ <br /> Tcg N; It�F.u�4 <br /> It.Type of building(check all that apply) q IntM <br /> or 2 Family DwJ <br /> elling—Number of Bedrooms Subdivision Name <br /> Plock a "--- <br /> ❑PublielCmranc.iel—Describe Use ❑City of I <br /> ❑State Oxned—Describe Use CSM Number C1 Village of <br /> V/ app 1/ra oa of LA- <br /> III.Type of Permit: (Check only one box on line A. Complete line B ifapplicable) <br /> A. ❑New System eplacement System ❑'I reztmenUHolding lank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑ Permit Revision ❑Orange mf Plumber ❑Pcrtnit Transfer to New I.ed Previous permit Number and Date issued <br /> livfare Expiration Owner <br /> IV.Type of POWTSS stem/CompanentlDevice: (Check all that ate) <br /> Yt`Iyon-Pressurized I.Ground ❑ Pressurized ln-Ground ❑ At-Gmde 1JMound,24in.ofsnimh1emil 010ound<24in.nfaaitzblesail <br /> ❑ I]old ina funk 0Othcr Dispersal Component(cxplmm) ❑Prcrvii m et Device(explain) <br /> V.Dis ersal/Preatment Area Information; <br /> Design Plmw(gpto I Design Soil Application Rate(Vilso Disperses)Area Required l) Dispers I Area Proposed(s0 System Eltiled o <br /> yso -7 Y3 (s �so 96-� <br /> VI.Tank Info Capacity in Tmal pot Manufacturer <br /> Gallons Gallons Units m e Yl 2 <br /> New Teak, Existing Tanks ” e $ <br /> 50 <br /> Septic <br /> or H A..8-L n4 <br /> O2 <br /> n6 Clamber S[7 V <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWI'S shown oro Reenacting plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRSNumx, Business Phone Number <br /> WADE RUFSHOLM , 1 227691 715-349-7286 <br /> Plumber's Address(Stmat.City,State,Zip Code) <br /> �if� <br /> PO BOX 514,SIREN,WI 54a72 <br /> V II.Count /De artment Use Only <br /> Approved ❑ Uisnpprovcd Permit 1'cc Due Issued Issuing Agent Signnmm <br /> ❑Owner Given Reazon for Rnial <br /> 5325. o wasi3 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Rp EC ENE <br /> OCT 2 3 2.113 <br /> nWrn mmmplr.ad.ne Ao.hcsarem.ad submdmme Cnunry amt^^nriam nor la.Nen W ulnrhnaxi- <br /> BURNETT COUNTY <br /> ZONING <br />