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�3peQ.a-X40 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, 53707-7162 �a7�7 <br /> �'�•���,�-- SF�i✓-15-43 <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 7 <br /> used for secondary purposes in accordance with the Privacv Law,s. 15.04(1)(m),Slats. <br /> I. Application Information-Please Print All Information / <br /> Property Owner's Name Parcel C'7-0/a-,1-`1045-36- - <br /> P 05 <br /> Property Owner's Ma fling Address Property Location <br /> � L� 1 � Govt. Lot -7 ,t�3 <br /> City,State Zip Code Phone Number b,Section <br /> 11") J �� (circle one) <br /> H. Type of Building(check all that apply) Lot v T d N; R %S E o�) <br /> 1 or 2 Family Dwelling-Number of Bedrooms J' SubdivstMrNu rte <br /> Block x/// GSfn �/1z,2- -)0 <br /> ❑ Public/Commercial-Describe Use - ❑ City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of <br /> Vol <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑ New System y 11 Replacement System X TreannenUHolding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑ 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 /> ❑ Nan-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(gpdst) Dispersal Area Required(so Dispersal Area Proposed(st) System Elevation <br /> VI. Tank Info Capacity in Total M of Manufacturer <br /> Gallons Gallons Units <br /> New TanksExisting Tanks 7i R <br /> 0 2 <br /> n. U in rn u, i U W <br /> Septic or Rokhrg-TYlik 1 , <br /> Dosing Chamber <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) Plu ber'�Signa lure ///'''"""))) 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. County/Department Use Only <br /> Approved ❑ Disapproved Permit Fee Date Issued Issuing Agen 'gnamre <br /> $ <br /> ElOwner Given Reason for Denial <br /> IX. Conditions of Approval/Reasons for Disapproval <br /> '"7ga, Br„Z/�vj w <br /> DJ <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 in x 11 inches i iz <br /> SBD-6398(R03/14) BURNETT CO NTY <br /> 7nKuP.tc <br />