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1aTA^F�ti�ry COUn <br /> t \a Safety and Buildings Divisions <br /> is S 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> y P s F.O. Box 7162 J 30 83� <br /> Madison,WI 53707-7162 <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 <br /> is required prior to obtaining a sant".permit. Noje�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 <br /> purposes in accordance with the Privacy Law,s. 15.04 1 m),Stats. <br /> I. Application Information-Please Print All Information U <br /> Property Own 's Name / d Parcel# o 7 0 (� ;P- 3 13 <br /> C D L/I/n �I/ <br /> Property Ownerrs Mailing Address Property Location / <br /> 5 0,2 Q (�r 4 e f` 'l d Govt.Lot / w� <br /> City,State Pip <br /> !C`oddee q Phone Number 7u y,, �W r/,, Section <br /> 45 /U /1 ���'/ !.��. �/ le one) <br /> T_'� ! N; R�E& <br /> R.Type of Building(check all that apply) Lot# <br /> Xor 2 Family Dwelling—Number of Bedrooms Subdivision Name <br /> Block# <br /> ❑Public/Commercial-pescribe Use ❑City of <br /> CSM N <br /> ❑State Owned-Describe Use � 11 Village of <br /> Town of /77 e— <br /> II1.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. New System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑ Penti t 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 appi <br /> ton-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 Arca Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> T Y3 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o ° <br /> ro v U f; .. ti <br /> New Tanks Existing Tanks o ;; <br /> Septic or Haklrr5Tmk ODa OL>Ca <br /> Dosing Chamber <br /> 1 6-576) !�5 0 11 1 _V_1 <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 1227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) (�✓L��w <br /> PO BOX 514,SIREN,WI 54872 <br /> VIII.Court 1De artment Use Only <br /> Permit Fee Date Issued Issuin Ag t Sign re <br /> Approved <br /> El <br /> ? p <br /> El owner Given Reason for Denial $ cJ '�O <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> p ECEWE <br /> Attach to mmptete plans for the system and submit to the County 0111Y on paper not less than a r 11 bes�m9LF O 2 <br /> 0 <br /> 15 <br /> -- -- — BURNETT COUNTY <br /> ZONING <br />