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County/� LL <br /> �A 1t Safety and Buildings Division ,%�4/"ifs e7/ <br /> I) 0 3 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> P S y � P.O. Box 7162 - r1 <br /> Madison,WI 53?5f r,9MPUTE S6 I <br /> 6�w <br /> Sanitary Permit Application State Trans <br /> y 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 q p <br /> purposes in accordance with the PrivacyLaw,s. 15.04(1)(m),Slats. / ��-' 1�l.� <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name 0 Parcel# O 7 0/ a <br /> / <br /> r e-C ) o? ©� po D /S�© <br /> Property Owner's Mailing Address Property Location/ P l <br /> Govt.Lot <br /> City,State Zip Code Phone Number � �� " �, S f <br /> q/ / (,�/ C•yll�'., W/., Section—Lo <br /> 73 6/a—!6J�'h ! b -Leone_ <br /> II.Type of Building(check all that apply) Lot# <br /> T 39N; R `� EoWi� <br /> .70I.or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use n' CSM Number ❑ Village of ',,��' <br /> V�� 7 G own of L-!F c An I <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) / <br /> A. w System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. El Permit Renewal El 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 apply) <br /> 7-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(sf) Dispersal Area Proposed(sf) Systpern Elevation <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o d <br /> New Tanks Existing Tanks w o <br /> a U <br /> Septic or ljoldingZanle C <br /> Dosing Chamber V V T� <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 / /�_ _�1 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 <br /> VIII.Countyy/De artment Use Only <br /> Approved ❑ Disapproved Permit Fee Date Issued Issuing Agent Signature <br /> ❑ Owner Given Reason for Denial $V �j - �� �Q'd-3 '�5 �L E <br /> IX.Conditions of Approval/Reasons forDisapproval �7 <br /> n,, JUN 7 7 7nig; nn <br /> 1 0 Attach to complete plans for the system and submit to the County only on paper not less than 8 1 11 hes in size <br /> BURNBTT COUNTY <br /> ZONING <br />