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,ptatN$Yr County <br /> R} ° Safety and Buildings Division Aw". C <br /> } s K� 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> P� P.O. Box 7162 SW X70 <br /> Madison,WI 53707-7162 �5 <br /> GArJ-((a <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this roan to the appropriate governmental unit <br /> is required prior to obtaining a sanitary pelmitl Note:Application forms for state-owned POW'1'S 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 <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m,Slats. <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Cla m pY1°/v e--L3 l IS 3 c7 Parcel# r3 7 a �� a <br /> /x1r3l lL y <br /> r <br /> rro�-l 61J L�.cA03 0,e:, C5 ©tea <br /> Property Owner's Mailing Address Property Location <br /> �f Govt.Lot <br /> City, tate Zip Code Phone NumberL f ,/ <br /> 5 �� /., Section <br /> (circle one <br /> H.Type of Building(check all that apply) }S Lot# I'� N; R��E or <br /> �' or 2 Family Dwelling-Number of Bedrooms Subdivision Name- <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use <br /> CSM Number ❑ Village of <br /> 3Z1'own of <br /> III.Type of Permit: (Cheek only one box on line A. Complete line B if applicable) <br /> A. p New System ❑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 ap, 1 <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(gpdsfl Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> d UD / <br /> VI.Tank Info apaci `ln Total #of Manufacturer <br /> Gallons Gallons Units 2 o o <br /> New Tanks Existing Tanks o ,$ R <br /> Septic or Mni tial ank 930 <br /> Dosing Chamber SO 0 ✓ �pU <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 / 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) �Lc <br /> PO BOX 514,SIREN,WI 54872 <br /> VIII.County/De artment Use Onl41 <br /> Approved ❑ D sapproved Permit Fee Date Date Issued /- issuing t Signature <br /> ❑ Owner Given Reason for Denial $�J76' <br /> IX,Conditions of Approval/Reasons for Disapproval ,/ / <br /> �(lfT �sfivTdiA/ I 0� CDIJP! ��sr GeCL, NO G(IFCC .J�tOlt/"Vii <br /> ! D i (���M� <br /> oN /"ZOT /4la-Al 111asd /Y7ee)L AIGG fet6ac�so C V <br /> MAY 31 2016 <br /> Attach to complete plans for the system and submit to the County only on paper not less than S s inches in size <br /> BURNETT COUNTY <br /> ZONING <br />