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caa <br /> a Safety and Buildings Division y�jJe <br /> 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> /1 P.O. Box 7162 <br /> S <br /> Madison,WI 53707-7162 K <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383 21(2),Wis,Adm.Cale,submission of this form to the ap,roprim.governmental unit <br /> is required prior to obtaining a sanitary permit. Note:Applicmiao forms for state-nu ed POW I S are submittal to Project Address(ifditfereat than mailing address) <br /> the Department of Safety and Professional Services. Personal information you provide may be used for secondary 1 <br /> purposes <br /> os s to accordance with the Priv [J Law,s. 15.04 1)m,Sims. 17 O-7 G-le/� D[-4 1. <br /> 1. Application Information—Please Print All Information <br /> Property Divot Name Parcel k d 1 O 6z 9`6 / <br /> (D / 05- oca p/,�OOC7 <br /> Properaf Owseis Mailing Addem Property location <br /> I <br /> o Vint ✓e S Goo.Lot Z <br /> City,Stole Zip Cade Phone Number y,, -4, Section <br /> c / e S b✓e /I7W 15s01 65-7 Y19--68 9 T_V_aN, If Eo <br /> �11/.Ty pe of Building(check all that a pply) Lotti <br /> Wq or 2 Family Dwelling-Number of Bedrooms_"I Subdivision Name <br /> 111''! I 1 I r Block <br /> D PuNiGCommercial-Describe Use <br /> ❑ City of <br /> Ell State Owned-Describe Use CSM Number ��❑l/whips,or <br /> ,y-sown of SGO <br /> 111.Type of Permit (Check only one boa online A. Complete line B if applicable) <br /> A_ ❑ New System /%Repiacpnert System ❑Treatment/Holding Tank Replacement Only ❑ Other Modificalims W Existing System(explain) <br /> B. ElPermit Rencwm ❑ Permit Revision ❑Change or Plumiser ❑Petmit Trensfcr m New first Previous Permit Number and Date Issued <br /> Before E."ornma Ownu <br /> IV.Type of POWTS S stem/Com onentlDeviee: Check ail that a i <br /> XNon-Presavrired ln-Grnund ❑Pressurized ln-Ground ❑At-Gade ❑ Mound>24 in.ofsuitaMe soil ❑ Mound<24 in,o'suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(cxplain) ❑Pretreatment Devioe(explmid <br /> V.Dis ersalffreatmcnt Area Information: <br /> DesignJ(gpd) Design Soil Application Rmep, dsQ DispersalArcaRcquimd(sf) Dispersal Arca Proposed(s0Sys(cm PJevation <br /> n a saVI.TaCapacity in Too) a of Manufacturer <br /> Gallons Gallons Units _New Tanks Exison,TanksiZwatts osib247More <br /> VII.Responsibility Statement- 1,the undersigned,assume reaponsibllity for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber'ss Si� MP/MPRS Number Business Phone Number <br /> WADE,RUFSHOLM 229691 715-349-9286 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX 5 M,SIRE-N,WI 54872 <br /> VIII.Count /Dc artment Use Onl <br /> VDI.Courved EJ Disapproved Permit Pee Urate Issued Is <br /> Agent Simmons <br /> ApprS 3zS.�� <br /> ❑Owner Given Kea or fur Denim <br /> IX.Conditions of Approva iReasons for Disapproval r� pnn2 <br /> art uST 645 2" covEl� �� � � ��r ins sr 4E i srvc�EDRD <br /> �'l��ll v iswtrHul V6A11R. . OCT 3' 2014 <br /> AHaeh to completeplana for the system andsubmit to the founts only on Pvper mol less rhanBlRallisize <br /> BURNETT COUNTY <br /> ZONING <br />