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�ppART1/CVT County <br /> Safety and Buildings Division ti/1/L) <br /> ( Q s <� 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> J P.O. Box 7162 I L' <br /> o� S� " Madison,WI 53707-7162 J p 11944 <br /> �xsatxA�' -1S <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 183.21(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 Services. Personal information you provide may be used for secondary l <br /> purposes in accordance with the Privacy Law,s.15.04 l m,Stats. � 7 i <br /> I. A Q oA�1 e6A <br /> Application Information-Please Print All Information <br /> Property Owner's Name Parcel#p.7 ©p ' <br /> i^/�^�J5f-,O 6A-X) cis— do IS®c�o� <br /> PTr <br /> rty Owner's Mailing Address Property Location 42c_ <br /> d f 9 t3 O-looI ' , I Govt.Lot 5' <br /> City,State Zip Code Phone Number y4, /4, Section/2 <br /> Lm(,K a4' ,�'y��' 3 circle one) <br /> 11.Type of Building(check all that apply) Lot# T N; R E or(r <br /> �1 or 2 Family Dwelling-Number of Bedrooms <br /> Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use �- �- ❑ City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> Flown of <br /> III.Type of Permit: (Check <br /> q only one box on line A. Complete line B if applicable) <br /> A. Elly <br /> New 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 /> IV.Type of POWTS S stem/Com onent/Device: Check all that a I <br /> ❑Nan-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.Dis ersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units i;•$ <br /> New Tanks Existing Tanks <br /> r2 s is <br /> Septic or hioW4*4"lr �- <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(Print) Plumber's Signature mpm,m Number Business Phone Number <br /> WADE RUFSHOLM zz� f 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) �l�' <br /> PO BOX 514,SIREN,WI 54872 <br /> VIII.Co un /De artment Use Only <br /> Permit Fee Date Issued Issuing A ignature <br /> [d P�pproved ❑Disapproved <br /> F./ ❑Owner Given Reason for Denial <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> ECEOVE <br /> Attach In complete plans for the system and submit to the County only on paper not less than Sir, 0 <br /> BURNETT COUNTY <br /> ZONING <br />