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Oye�aaarhyT County <br /> Safety and Buildings Division ,�f, <br /> '� 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> P.O. Box 7162 <br /> Madison,WI 53707-7162 <br /> "�'VSAO;snV <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(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 th mailing address) <br /> the Department of Safety and Professional Services. Personal information you provide may be used for secondary / <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel#0,. p oZ — -aZ <br /> O -000 ' f� <br /> Property Owner's Mailing Address Property Location p L <br /> �j•7 or. (`: AC' 4 jv 4!0 Govt Lot <br /> City,State Zip Code ` Phone Number / // ^/15 y, 1)0 y,, Stion_ <br /> A) .5 0 7 6 76 3 �5'IE' 27-7 � i (circle <br /> one <br /> T �N; R�Eo.& <br /> II.Type of Building(ch6ck all that apply) Lot# <br /> or 2 Family Dwelling-Number of Bedrooms 3 Subdivision Name _J <br /> _ Block# <br /> ❑Public/Commercial-Describe Use ❑ City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> Town of U S <br /> III.Type of Permit: (Check only one boa 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 Plumber List Previous Perri[Number trod Date Issued <br /> ❑Chan ❑Permit Transfer to New <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: Check all that apply) <br /> 1 ,Non-Pressurized in-Ground ❑Pressualmd In-Ground ❑At-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pfem`hnent Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(st) Dispersal Area Proposed(st) System Elevation <br /> ..-7 <br /> �b y3 <br /> VI.Tank Info Capacity in Total #of Manufacturer c <br /> Gallons Gallons Units <br /> New Tanks fixistiug Tasks u c °��' <br /> P.U n 00 w t7 i <br /> Septico Wang-. �U� pDU 0 r w e sc-e <br /> Dosing Chamber <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber��re n MP/MPRS Number Business Phone Number <br /> WADE RUFSHOLM //J` 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 <br /> VM County/Department Use Only <br /> Approved ❑ Disapproved Permit I= A Date Issue( Issuing Agent Si <br /> ❑ Owner Given Reason for Denial $J 7J ' 7 7 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> D ECEIVE <br /> Attach to complete plans for the system and submit to the County only an paper not less than Sin I i 2017 <br /> -- -- --- BURNETT COUNTY <br /> ZONING <br />