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County <br /> ".I Safety and Buildings Division BURNETT <br /> 1400 E Washington Ave SaNtare Permit Number(to Be,filed in by Co.) <br /> Pr P.O. Box 7162 n n <br /> S�)- Madison,WI 53707-7162 J� /37D <br /> absrcre,x`' GST (S'DI 56n/— <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383'1(2), Wis. Adm. Code, submissiform on of this foto the appropriate inseminated (ouwt IC hold r) <br /> mat is required prior to obtaining a sanitary permit. Nom: Application ponos for state-owned POWTS are Project Address(if different Nun mailing address) <br /> mhmined in the Department of Safety and Professional Services. Personal information you provide may be <br /> used for secondary ses In accordmwe with the Privacy Law,s. IS.M(q(m .Sun. //�� r / <br /> I. Application Information-Ishoue Print All Information 10I po 0 r G6�'/ <br /> Property Owner's Name .J f Z Parcel M CS-) 0 2 D .?. H /6 <br /> KBO / r� { 2rJc,KS 165- 5 O5 -1 03 006 <br /> Pro anyy/O C is Sts in,Address �1 /� Property location <br /> I/_ t'7 () 21,+ k /„ l e"" u r Govt.Lot <br /> City,Suite Zip Cale Pheoe Number <br /> U. u.secdon <br /> cc�e J rAne mom• <br /> 5-5-3 Y 651 9ay-1763 (enel°ane) <br /> 11. Type of Building(check all that apply) Lot M T �N: R B o(D <br /> or 2 Family Dwelling-Number of Bedrooms 12 51 4l Stitsdiniter Name '/ <br /> Block# r\ '+���o(..J L'qRe_ <br /> G Pubrctcmmnercial-Rseribe Use G city of f <br /> ❑Sure Owned-Describe Use CSM Plummer G Village of <br /> Town of /4'N " <br /> 111.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. I�Ness Sstem G Re lacemem S rmm Tremaxna/Holding Tank Re lowment Only G Other Medification to Existing S>atem <br /> (eplam) <br /> B. ❑ Permit Renewal G Permit Revision ❑ Change of G Panot Tramfer m New List Previous Permit Number and Date Issued <br /> Before Expiration Plumper Owner <br /> IV. Type of POVITS System/Corn neon/Device: (Check all that apply) <br /> X-Non-PressuriuJ In-Grund G Pressurized Iry Ground G A,Grace G Mutual > 24 in.of,.i.blc .it G Mound < 24 in,of suitable .it <br /> G Holding'1ank ❑Other Dispersal Component(explain) G Pretreatment Device(explain) <br /> V. Dis rsal/Troatmcut Area Information: <br /> Design Flow(,pd) Design Soil Application Rate(gWsO Dispersal Area Required(so Dispersal Are.Proposed(s0 System Elevation <br /> 30C> , 7 V„29 yso E- 5- <br /> V1.Took Into Capacity in Total #of Manufacturer <br /> Gallons GAImn Cut is <br /> New Tanks Econ,Tons, _ <br /> Sephe or He'dmgTted 7 <br /> Dowing(lTvnhcr <br /> VII. Responsibility Statement- I,the undersigned,assume mpunobility Be,intallati er or the proa7S shown on the attached loans. <br /> Plmnber's Name E.... o Plumber's Signa mu, MPIMPRS Number Business Phone Number <br /> WADE RUFSHOLIA 22'/691 715-Y19-7286 <br /> Plumber's Address(Street . City.Stove.Zip Code) <br /> M BOX 514.SIREN.WI 54872 <br /> VIII. County/De artmenl Use Ont <br /> Of Approved G DisappmvW Permit Fee Dae hosed Issuing Signature <br /> d5 �o <br /> G Owner Given Reason @r Denial 5 <br /> IX. Conditions of ApprovallReasons for Disap rocs a] <br /> .Ww'h to complete Peanx fur the—trm nml wuM1mit to the County only on paper nom leo thin 8 e-4 x 11 Inches in six, <br /> SBD-6398(R03114) <br />