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T <br /> AarSul ev Safety and Buildings Division <br /> D$ 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> rp S P.O. Box <br /> „C Madison,WI 53707707-7162 <br /> �TaSKrh4� J <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 G oV A-ly Aevei w <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 p� ' 9 G K <br /> purposes in accordance with the PrivacyLaw,s. 15.04 1 m,Stats. a / / NS G lJM <br /> L Application Information-Please Print All Information <br /> Property Owner's Name rcel Pa # p 7'el <br /> r11 'Vo V T e 15r e2 -5'- oo?�c�av <br /> Propertty Owner's Mailing Address a Property Location <br /> 7 7y r 74 Govt.Lot <br /> City,State Zip Code Phone Number y. /. Section <br /> A.) �'05 (circle one) <br /> H.Type of Building(check all that apply) Lot# T��N; e E or W <br /> 3 Subdivision Name <br /> �l or 2 Family Dwelling-Number of Bedrooms 3 2 79r <br /> Block# �i}itJs�a/17 4+k� 5/7cr^�s <br /> El Public/Commercial-Describe Use <br /> ❑City of •� <br /> ❑State Owned-Describe Use <br /> CSM Number ❑Village of <br /> -- Wrown of <br /> IIL Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑New System I .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 omonent/Device: Check all that apply) <br /> .11-Non-Pressurized In-Ground 11Pressurized In-Ground El At-Grade ❑Mound>24 in.of suitable soil 11Mound<24 in.of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Irifoernationi <br /> Design Flow(gpd) J Design Soil Application Rate(gpdsf) Dispersal)Area Required(sf) Dispersals Proposed(st) System Elevation <br /> �fSO i v 77 II U <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units U $ F y <br /> New Tasks Existing Tanks c 8 <br /> Septic or„-'.o..'u%Z4mk <br /> Dosing Chamber /Peo G-env l <br /> VII.Responsibility Statement-1,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.Coun /De artment Use Only <br /> ,y Permit Fee Date Issued Issuing Agent Sigr,,/ /, <br /> tp LO I <br /> Approved El Disapproved $ � 0 0 <br /> Yt ❑Owner Given Reason for Denial �`� -6--& -I <br /> IX.Conditions of Approval/Reasons for Disapproval i 1aN sr!om GK E-Ziv fO r- ZONt A To Re <br /> l/sCalo r 1/'l A/ /q;st't^ +- Vt+.vf ye;9,{f, /Z- I/fJLow Orc;ry Ae;l� To �uy'- a f`aet�Pla:v <br /> D -EC� EoVE <br /> Attach to complete plains for the system and submit to the County only on paper not less than 8 1/2 z 11 1 size <br /> MAY 0 6 2016 <br /> BURNETT COUNTY <br /> 7_C,'!•,i; a <br />