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` pprAR7MFyro� County <br /> ��� Safety and Buildings Division BURNETT 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 Ttion Number <br /> In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental G�o�-va JY u14t,-) <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 �# <br /> used for secondarypurposes in accordance with the PrivacyLaw,s. 15.04 1 m),Stats. f J �l /� / <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# 0 7 0-3,2 -2, `Yl T 6 j 6 <br /> le te'.AJ �� 3� o0 r-) 0/2 ell T6 <br /> Prop <br /> e <br /> rty Owner's Ma fling Address Property Location f-j <br /> Govt.Lot <br /> City,State Zi Code Phone Number L <br /> Y (r� P / /�-- _ � �k,„�CiJ �/a,Section f <br /> e i lam'/-Gs r/e 7 C,/F� h-' l y 7� _ �s 5- (circle one) <br /> H. Type o uilding (check all that apply) Lot# T- �N; R E otQV <br /> Al or 2 Family Dwelling-Number of Bedrooms � � Subdivision Name <br /> Block# <br /> ❑ Public/Commercial-Describe Use ❑ City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of <br /> V1 j- p / /;;t_ Y Town of J eyl� 5 <br /> III. Type of Permit; (Check only one box on line A. Complete line B if applicable) <br /> A. O-New System ❑ Replacement System y p y ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. El Permit Renewal ❑ Permit Revision <br /> ❑ Change of ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> fV. Type of POWTS System/Component/Device: (Check all that apply) <br /> ,gNon-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.DispersaUTreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(s0 System Elevation <br /> 5`� , —7 � 7 e<-:5-6 q <br /> VI. Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units ar o v <br /> New Tanks Existing Tanks <br /> m <br /> Septic or WoM ng-T3nk /s a f D ,�a �. X <br /> Dosing Chamber G� G T� <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Priv t) Plumber's Signa rare MP/MPRS NumberBusiness Phone Number <br /> WADE RUFS14OLM )G / /J 227691 715-349-7286 <br /> L :2-c�ft• �i's- ?-'-- <br /> Plumber's Address(Street ,City, State,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 <br /> VIII. Count /De artment Use Only <br /> .�Approved 11 Disapproved Perini[Fee Date Issued r Issuing ge Si lure <br /> ❑ Owner Given Reason for Denial S 3757` <br /> tX. Conditions of Approval/Reasons for Disapproval <br /> C-C;T- is- 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 <br /> SBD-63398 (R03/14) <br />