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County <br /> j Safely and Buildings Division <br /> f� N J e <br /> _ . <br /> "'cr� 1400 E Washington Ave Sanitary Permit Number(to be filled in M1y Co.) <br /> � ?s i P.O. Boa 7162 57CI& 93y <br /> r\� )c Madison,WI 53707-7162 <br /> " <br /> Sanitary Permit Application State I maintains Number <br /> In accordance with SPS 383?I(2),We,Adm.Code,submission ofthls form re the appropriate govemmenml unit <br /> is required prior to obtaining a sanitary permit. Note:Application forms for state-owned POW FS arembmitted to Projed Address(if diBercnr than mailing address) <br /> the Depatlment o'SatLly and Professional Services. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privpc Law,s-15.04 1)1m),Studs. J^ _ <br /> 1. Application Information-Please Print All Information parce,U O"7 a G OIL aZ <br /> Pmpc^^nyyy--Owner's Name // <br /> : I_AA)e f/}Cob50nl s S net n 700D <br /> Property Owner's Mailing Address Property LocationPa/ <br /> 7,; G a G A�C;c <br /> Govt Lat -2 <br /> City,State I'honc Number 'G, %, SectionIt (circle one <br /> 11.Type of sitting(check all that apply) I'mq <br /> aSubdivision Name <br /> �+or2 family Dwelling-Number of Bedrooms <br /> Block a <br /> ❑PiRi ic/Cra masuil-Baseline Use ❑ City of <br /> CSM Number D Village of <br /> ❑Slate Owned-tic'enb:Use O��i/y,grJ <br /> I ;V'1"own of <br /> III.Type of Permit: (Check only one box online A. Complete line B if applicable) <br /> A' ❑New System `�Itedecemmn System D ITeamant/Holding'fark Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal Ll Permit Revision D Change orPhorne, D Permit'I'musfcr to New Iasi Previous l'eemit Number end Date lssucd <br /> Before Expiration Owner <br /> .I-VV.T eof POWTSSstem/Comonent/Device: Check an that n 1 <br /> (Non-Prcssurized In-Ground ❑Pressurized In-Ground DAt-Grade D Mound>24 inofseitable soil D Mound<24 in,ofsamble soil <br /> D Holding Tarek D Other Dopereal Component(explain) D Freemason Device(explain) <br /> V.Dis ersal/Treatment Area Information: <br /> Design Plow(gpd) Design Soil Application Rate(gpdd) Dispersal Arca Rcquirrd(s0 Dispersal Area Proposed Ed) System Elevation <br /> X00 1S God Goo 5- <br /> VI.Tank Info Capacity in Total A of Maaufacwrcr <br /> Gallons Gullons Units a <br /> New Tanks li.nring Iankr S U = 2 v4ei <br /> Seth- auk <br /> Dosing Chamber 75'V $Z <br /> VII.Responsibility Statement- 1,the undersigned,assume respmrsibility,for hour urs or the POWCS shown en the attached plans. <br /> Plumber's Name(Prim) Plumber's Signalurc 227691 SNumber 715-349-Phone Number <br /> WADE RUFSHOLM 227691 ]IS-349-R86 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 <br /> VIII.Count /De artment Use Only <br /> Approved ElDisapprnvcd > <br /> Permit Fee Date Issued Issuing Agent Signature <br /> ❑OC iven accun for Denial JZ 5-.a- (D- L-/y /� /u" <br /> wner � <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> La✓S, DFD /N7EBIM PWMeV(. G2ann Nicadtc ccA7/G iN,.Cr uF <br /> New 5.T. IJI <br /> JUN - 2 2014 <br /> Attaeb to mmplNe Mvm far the usF.e.J submit to[he cun.,only an W prr we less than 8 l Inches in me <br /> BURNETT COUNTY <br /> - ZONING <br />