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,.i�Feartrftgyr� COntny„ <br /> Safety and Buildings Division ,[/J�(y�^ e__ <br /> F i S .1j� 1400 E Washington Ave San Pi bar(P be filled in by Co.) <br /> j SP '� !` P.O. Box 7162 R <br /> Madison,WI 53707-7162 — <br /> J 7C l�- <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 forts for state-owned POWTS are submitted to Project Address(if different than mailing address) <br /> the Department of Safety and Professional Services. Personal information you provide may be used for secondary ���� P�� <br /> purposes in accordance with the PrivacyLaw,s.15.04(1 m),Stats. KCj <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel#©7 036 0? O 1702- — <br /> 14�J1 1 (L- -/—e 4-J / S 05- 00/ 0.;20000 <br /> Property Owner's Mailing <br /> 7.5 Address Property Location/CC/ <br /> s `'N c e LAJ Govt.Lot_ <br /> City,State Zip Code Phone Number V, /., Section %S <br /> U6(SO�J l.J `�d/ �s/ a3 s=6sz (circle one <br /> T �N; R�Eo <br /> II.Type of Building(check all that apply) Lot# <br /> A]or 2 Family Dwelling-Number of Bedrooms � � Subdivision Name <br /> _ Block# <br /> ❑PublirJCommercial-Describe Use ❑City of <br /> ❑State Owned-Describe Use -- CSM Number ❑Village of <br /> 0-Town of G f/-L) J J� <br /> III.Type of Permit: (Check only one boa on line A. Complete line B if applicable) <br /> A. ❑New System -9 Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS S stem/Com onent/Device: Check all that appi <br /> Non-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(st) Dispersal Area Proposed Of) System Elevation <br /> 3ov . S GG © � ac� 9G, 6 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> 0 <br /> Gallons Gallons Units o v 8 y <br /> New Tanks Existing Tanks w o a R <br /> n.U rn y w C7 w <br /> Septic or Hdidftrg'&nk Q 0 <br /> Dosing Chamber cg�J t� y <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature 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 /> VIII.County/Department Use Only <br /> Approved ❑Disapproved Permit Fee 0,0 Date Issued Issuing Agent$ 37s — Sign e <br /> A ❑ Owner Given Reason for Denial / � [� ��7 <br /> DL Conditions of Approval/Reasons for Disapproval <br /> Ael A& nD ECEPVE <br /> m 11 --- n <br /> Attach to complete plans for the system and submit to the County only on paper not Icss than 8 01 <br /> z twbell <br /> BURNETT COUNTY <br /> ZONING <br />