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Safety and Buildings Division G f,Aj e <br /> 1400 E Washington Ave Sanitary Permit Number(t be filled m by Co.) <br /> P P.O. Box 7162 / <br /> S � Madison,WI 53707-7162 <br /> �`a.+1QIvPi. <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 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,Stats. u ' <br /> I. Application Information-PleasePrintAllInformation /v, o/� <br /> ArL <br /> Pro rtyOwner's N /� Parcel# 0 7 041,2 v2 -7,? le� 2 7 <br /> 7��Ir // d a 'L) S- 15-3sy o -2 en,e) a <br /> Property Owner's Mailing Address f Property Location <br /> '3001 G /q l0>` // /11/�P—• -5 Govt.Lot <br /> City,State t Zip Code Phone Number y+ <br /> �/ / /+, Section_7 <br /> LC7 U/S ��r yn J S/o�(� (circle on <br /> /rl T�N; R�_Eo Wr <br /> H.Type of Building(check all that apply) 77 Lot# _ <br /> ❑I or 2 Family Dwelling-Number of Bedrooms 7, —3 2 Subdivision Name ,,� <br /> Block# -J 2, 15 P_Jam, 41//-A . c_ 1 <br /> cvc oC <br /> ❑Public/Commercial-Describe Use I El city of •— <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> Townof <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. V\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 System/Component/Device: Check all that apply) <br /> ❑Non-Pressurized In-Ground ❑Pressurized In-Ground ❑ At-Grade ❑Mound>24 in,of suitable soil ❑Mound<24 in.of suitable soil <br /> Akiolding 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(sf) System Elevation <br /> VI,Tank Info Capacity in Total #of Manufacturer Y c <br /> Gallons Gallons Units a L+ $ <br /> New Tacks Existing Tacks c <br /> 6.U V] m tq U. <br /> Holding Tank 00 ;?dD 0 ,q <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(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> WADE RUFSHOLM /pJ J 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 <br /> VIII.C77aiv_ <br /> IDintent Use Only <br /> Apprved Permit Fee O Date Issued Issuing Agent Signature <br /> en Reason for Denial $37:57 O41-27-16 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> APR 26 2016 <br /> Attach to complete plans for the system and submit to the County only on paper not less tha 1 /1 inches in size <br /> BURNETT COUNTY <br /> l- - - - ZONING <br />