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�otr"ar"'evr�� County <br /> Safety and Buildings Division BURNETT <br /> 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> P.O. Box 7162 <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 <br /> unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are Project Address(if different than mailing address) <br /> submitted to the Department of Safety and Professional Services. Personal information you provide may be /Q /� % /�- 2- <br /> used <br /> used for secondary purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. /O P <br /> I. Application Information-Please Print All Information ee_�SS <br /> Property Owner's Name <br /> Parcel# O -7 CS 3<1 37 /x/2 <br /> T �- <br /> Property Owner's Ma iling Address / Property Location <br /> ?o 3� �- �l p� /U 07- <br /> Govt.Lot <br /> City,State Zip Code Phone Number , <br /> i _ r b, V,,Section L <br /> 'd GU 'A) (�� 5 /7/ ,�d �`fc�� �l (circle one) <br /> H.Type of Building(check all that apply) Lot# T=N; R /a E oK <br /> Al or 2 Family Dwelling-Number of Bedrooms 7 Subdivision Name C� <br /> Block# L o Jq f r -5 gam- J <br /> ElPublic/Commercial-Describe Use <br /> ❑ City of — <br /> ❑State Owned-Describe Use CSM Number ❑ Village of <br /> Town of />iFa' <br /> III. Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' ❑ New System pRe lacement System <br /> Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. El Permit Renewal El Permit Revision <br /> ❑ Change of ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IV. Type of POWTS System/Component/Device: (Check all that apply) <br /> ❑ Non-Pressurized In-Ground ❑ Pressurized ht-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 Sail Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> VI. Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o <br /> New Tanks Existing Tanks u c <br /> mor Holding Tank <br /> Dosing Chamber <br /> VII. Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Prin t) Plumber's Signa tune MP/MPRS Number Business Phone Number <br /> WADE RUFSHOLM / 227691 715-349-7286 <br /> Plumber's Address(Street ,City,State,Zip Code) <br /> PO BOX 514,SIREN, WI 54872 <br /> VIII.Count /Deartment Use Only <br /> Approved ElDisapproved Permit Fee Date Issued Issuing Agen Signature <br /> ❑ Owner Given Reason for Denial $ 3 70' 0-�o <br /> IX. Conditions of Approval/Reasons for Disapproval <br /> 116a,vg %Ra,e &,rf No4,Z•v�l;u/,p -lo Qe 7.je `LaJ;?Ove. <br /> MAY 19 2015 <br /> BURNETT CO <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 112 x 11 inches in size ,ZONING <br /> SBD-6398(R03/14) <br />