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�ogerasargvr <br /> Safety and Buildings Division County, �t/`� 'L <br /> 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> p t� t P.O. Box 7162 S 1� Madison,WI 53707-7162 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 393.21(2),Wis.Adm.Code,submission of this firm 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 <br /> purposes in accordance with the Privacy Law,s.15.04(1 m),Stats. <br /> L Application Information-Please Print All Information <br /> Property Own S Name Parcel# ©7 G 116 ;? 3 9 �9 3 <br /> ('6 ,') ter" O/ 000 0//600 <br /> Property�Owner's Mailing <br /> Ad s Property Location <br /> pq f // Add <br /> �s Govt Lot <br /> City,State Zip Code Phone Number _ %SS 14, Section 3 <br /> /f0 35 / (circle one <br /> T �LN; R17 <br /> EL Type of Building(eleek all that apply) Lot <br /> # <br /> 1 or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block# <br /> ❑PubliclCommeroial-Describe Use ❑City of -- <br /> ❑State Owned-Describe Use CSM Number ❑ Village of <br /> Town of <br /> III.Type of Permit: (Check only one boa on line A_ Complete line B if applicable) <br /> A. ❑New System J211keplaccincot 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 app1 <br /> Pressuriud 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 Raw(gpdst) Dispersal Area Required(st) Dispersal Area Proposed(sf) System Elevation <br /> ® d / 7 ysys D S S <br /> VL Tank Info Capacity in Total #of Manufacturer &' <br /> Gallons Gallons Units v'o <br /> New Tanks Existing Tanks tic g `� <br /> a U i7i o, iL C7 w <br /> Septic or ffiMl6TTS 9 00) <br /> Dosing Chamber -5-0 7 <br /> 5-0 <br /> VIL Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Si re WIWRS Number Business Phone Number <br /> WADE RUFSHOLM 227691 715-349-7296 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX 514,SIREN,WI SU72 <br /> VIM County/Department Use Only <br /> Approved ❑Disapproved Permit Fee D Date Issued Issuing Agent Signature <br /> ❑Owner Given Reason for Denial <br /> % /-A/,0 <br /> 3�s' y_J -7 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> DECENE <br /> 1 ')n17 n <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 V2 z inch in size <br /> BURNETT COUNTY <br /> ZONING <br />