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County _ <br /> I`'�-� ` Safety and Buildings Division BURNETT <br /> c X 1400 E Washington Ave Sanitary Permit Number(to to Filled in by Ca) <br /> P j P.O. Box 7162 /7 7 <br /> S / <br /> . Madison,Wl 53707-7162 / /3 qq <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(2), AVisAdm. Code, subm-icsion of this form to the appropriate governmental V i Cu/ <br /> unit is required prior he obtaining a sanitary permit. Nota: Application forms for smtcoweed POWTS are Project Address(If different than mailing address) <br /> submitted! to to the Department of Safety and ith the <br /> Services. Personal information you provide may beise `�� �� <br /> sub I.,secondary Purposes in a Safety and <br /> with the conal Law,s. I Personal in rmati 1 <br /> I. Application Information-Please Print All Information / <br /> Property Owners Name�, / ) Parcel#07 <br /> tVjv a' C'—'J 5- S- dS o oi'CJ CNS <br /> P,o,,,y Owner's Ma\\ling Address -- /1 ,r I/ Property Location <br /> L11,2o ^/C A/ (a- L/V i /v Govt.Lot <br /> City,State Zip Cale Phone Number a <br /> ta, E,Scctian <br /> Pl/;71 q ��/L) 5'Yyf� 6/ -965 a a8 (encle one) <br /> II. Type of Building(check all that apply) Lot# T N: R /./j— E or WO <br /> o12 Parody Dwelling-Number of Bedrooms Subdivision Name <br /> —� Block is S/� L; r G'/rev Q(N/•° l/ <br /> ❑Pubhc/Cmemerm.1-Dccdbe Use ❑ City of <br /> 11 State Owned-Describe Ilse CSM Number ❑ Village of <br /> PTownof ,'�igG�Sar✓ <br /> III.Ty���--pyyye���of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. New System ❑ Replacement System ❑ Treatment/lidding Tank Replacement Only ❑ ONar Mpdducation to Existing System(explain) <br /> B. ❑ Permit Renewal ❑ Permit Revision � Charlie of ❑Permit Ttarts(er to New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IV. <br /> 'vpe of POWTS 5 stem/Com onenl/Device: (Check all that apply) <br /> ,YNon-Pressurized In Ground ❑ Pressurized InG....d ❑ A,-Grade ❑ Mound > 24m.of,c,(.ble .if ❑ MouM < 24 inif rvitahle .it <br /> ❑ holding Tank ❑Other Dispersal Component(explain) ❑P¢ laithe at Device(explain) <br /> V. Dis real/Treatment Area Information: <br /> Design Plow(gpd) Design Soil Application Rate(gpds0 Dispersal Area Required(e0 Dispersal Area Proposed(s0 System Elevation <br /> /5-4� ' 7 a15 ado ys, <br /> V1. 'Tank Info Capacity in 'focal #of Manufacturer <br /> Ginnie, Gallons Units E _ <br /> NewTanks tsirung Tanks <br /> aC L <br /> Sopor rr wlswya:m; 7-5 OC54- <br /> — <br /> D—ng CnmmIrr <br /> VII. Rasps nsibilily Statement- I,the undersigood,assume recpmuibllily for installation of the POINTS shown on the attached places. <br /> WADI.Piturcva"041-- <br /> x Name(Prin B Plulnleei s Signa tare ^ 227691 S Number Business 286 Number <br /> WADE RUFSHOLM ' 11 A /r//" 227691 915-349"Y181 <br /> Parriwee Address(Street,City.Stats,Zip Cale) RG�P <br /> PO BOX 514,SIREN,WI 54872 <br /> VIII. Count /De ar�Uu�k2Approvd ❑ DPermit Pu Dam lzsued Issuing Ag afore❑ Ofar Denial $���.Qt/ Wu-1IN <br /> IX. Conditions of Approval/Reasons for Disapproval VEn <br /> JAN 262015 <br /> m _ <br /> Atwcn to rnplen ylan.tar the ones:moria w me Crum,may on oyer not less @an 6 nz x tt InRnn <br /> SBD-6398 (803/14) BURNETT COUNTY <br /> ZONING <br />