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/oE°"aa'r�p County Safety and Buildings Division u r r(J <br /> tt jj 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> ,3p ` Sp I P.O. Box7162 <br /> Madison,WI 53707-7162 � <br /> Sanitary Permit Application State Transaction Number <br /> in accordance with SPS 38321(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 di" an mailing adgress <br /> the Department of Safety and Professional Services. Personal information you provide may be used for secondary -7�2 6 0 /11 i eY -5-^1 /1 <br /> purposes in accordance with the Privacy Law,s.15. l m Stats. <br /> L Application Information—Please Print All Information 7 <br /> Property Owner's Name Parcel# O 7 0 g p i2 O 16 336, <br /> e—r zl C 0 003 C5/ 7 <br /> Property Owner's Mailing Address Property Location /0 <br /> Q I.-der L Govt Lot _ <br /> City,State FZip—Code <br /> / Phone Number /, r/,, Section <br /> .7 AJ �!/CJ T _N, R / (°uc]Eoone)' <br /> II of Building(check all that apply) Lot# <br /> Subdivision Name <br /> ❑ 1 or2 Family Dwelling—Number afBedrooms _ <br /> Block# <br /> gPublidCommercial—DescdbeUse Pr <br /> S ❑City of <br /> 1�sfu CSMNumber ❑Village of <br /> El state owned—Describe Use [<JTown o£ <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' ANew System ❑Replacement System ElTreamnent/Holding Tank Replacement Only ❑Other'Modification to Existing System(explain) <br /> ` \ List Previous Permit Number and Date issued <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New <br /> Before Expiration Owner <br /> IV.Type of POWTS S mlCom onent/Device Check all that apply) <br /> ❑Non-Pressurized in-Ground ❑Pressurized In-Ground ❑At-Grade ❑Moond>24 ua.of suitable soil ❑Mound<24 in.of suitable soil <br /> Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatrnent Device(explain) . <br /> V.Dis ersalfTreatment Area Information: <br /> Design Flow(gpd) 7N�— <br /> Soil Application Rate(gpdst) Dispersal Area Required(st) 7e , <br /> System Elevation <br /> VL Tank Info Capacity in Total #of <br /> Gallons Gallons Unitssg U s <br /> lcs 1%�8 <br /> .iaptwar Holding Tank _Jam,0© �d <br /> Dosing Cbambm <br /> VIL Responsibility Statement-L the undersiTgned,assume responsibility for installation of the POWTS shown on the attached Plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Nwnber Business Phone Number <br /> WADE RUFSHOLM 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 <br /> VM Conn /De artment Use Out <br /> Pere?nit Fee 0/ Date Issued Issuing Agent Si <br /> Approved 0 Disapproved Owner vw Reason for Dial $ 1 7S 3" 7 7 <br /> ffi Conditions or App"vavReasons for Aisepproval <br /> RECE0VE <br /> Attach to completeplans for the system and submit to the County only on papernot less ' 2017 <br /> --- ---- ---- BURNETf COUNTY <br /> ZONING <br />