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3'TraRTMp,�,TO County <br /> Safety and Buildings Division BURNETT <br /> ( 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> P.O. Box 7162 7 <br /> Madison,WI 53707-7162 -:;S 705 <br /> Sanitary Permit Application State Trans. tion Number <br /> In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental o <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),Stats. �� �%L 1�/1 <br /> I. Application Information-Please Print All Information �j 7 � <br /> Property Owner's Name Parcel# c 7 002 6 �2 <br /> J}/l� / oN v/56�c� <br /> Property Owner's Ma ilinJgp\Ad s -}' Property Location <br /> / e 0 C� s / ; Govt.Lot <br /> City,State Zip Code Phone Number , <br /> k, /.,Section 1-2 <br /> VI�JA) & _ 7 (circle one) <br /> II. Type of Building (check all that apply) Lot# T G N; R�E ol�D_ <br /> All or 2 Family Dwelling-Number of Bedrooms j r/ -5— Subdivision Name <br /> Block# C3 // L K e- L <br /> ❑Public/Commercial-Describe Use —� �— <br /> ❑ City of <br /> ❑State Owned-Describe Use rumr w❑f Village of <br /> try Town of <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' ❑ New System Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑ 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 /> ANon-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(sf) System Elevation <br /> 30 0 y�� s� 9y, <br /> VI. Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons units <br /> New Tanks Existing Tanks c 2 <br /> ri U �, vn 4. CD a. <br /> Septic or Holdu*Zaal— �— <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 rare / MP/MPRS Number 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 /> VIII.County/Department Use Only <br /> Approved ❑ Disapproved PermitFeeDate{Issued Issuing Signature <br /> 11 Owner Given Reason for Denial '0 /�� LWML <br /> lL �OtS <br /> IX. Conditions of Approval/Reasons for Disapproval A! � <br /> APR 2 0 2��011vv//1f f��(1�j5 <br /> Cs i, I�- �� V Attach to complete plans for the system and submit to the County only on paper not less than 8 112 x 11 inc M COUNTY <br /> r..J <br /> SBD-6398(R03/14) ZONINGt T <br />