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Cour <br /> %,.T <br /> Y/ '+,c Safety and Buildings Division (L'11C <br /> b' "`I 201 W.Washington Ave., P.O.Box 7182 Sanitary Permit Numbcr(lobe filled in by Co.) <br /> Madison,WI 53707-7162 <br /> Sanitary Permit Application Spezramoselion 33lso8be <br /> In accordance with SPS 38331(2),We,Adm.Cole,submission of this Ibrm In the appropriate govemmemal mtit <br /> is required prior to obtaining a solitary permit Note:Application forms for stale-owned POW-1 S are submitted m Project Address(if di Bcmnt they mailing address) <br /> the Department of Safety and Professional Servies, Personal information you provide may be used for secondary / �r <br /> policies in accordance with the Pusic Law,s. 15.041 m,Sees Z o ! eejAO k <br /> I. Application Information-Please Print All Information <br /> Pope 0yner's Npme - / / I'mul p 0 7 U Q / -� <br /> be.^`r STs///'eLAlt 5--o-6- <br /> Propriety <br /> sowPropriety Owner's Mailing Address Property location <br /> o35T L wo��/ k� GavLlnt 6 _ <br /> City,slate Lip Cade Phone Number A. 'A Section 2Z <br /> Graa�564f ��(mrdeon <br /> Tag N; RJ�Eor orb <br /> 11/.Type of Building(c eck all that ap ply) Lock <br /> 0Ti r 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block k <br /> ❑Public/Cmemereiei-Describe Usc ❑City of <br /> — CSM Number 0 Village of <br /> ❑State Owned-Describe Go, <br /> ser t:,kl0001 <br /> 111.Type of Permit: (Check only one box on line A. Complete line B if applicable) ' <br /> A. 0New System O Replacement System OTreatmcndllolding Tank Replacmem Only ❑Other Modificarlon to Existing System(explain) <br /> B. ❑Permit Renewal 0 Permit Revision 0Chmgeof Plumbcr 0Pcmtitlmnsferm New List Previous P<mot Number end Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS S stem/Com onent/Device: Check all that apply <br /> 0 Nan-Pressurized In-Ground 0 Pressurised Io-Ground 0 Atlimde 0 avmxx 124 in.afiuilablc soil 39Mound<24 in.ofsuhable sail <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) O Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design plow Bcxt Design Soil Application Rate(gpdsf) Dispersal Area Requited(s1) Dispersal Area Proposed(If) System Elevation <br /> S61 9 y s o "1 o cT� <br /> VI.Tank Info Capacity in not qof Manufacturer <br /> Gallons Gallons Units <br /> New red, Exiuing Tanks 0 U <br /> A. <br /> U 1 <br /> some ex ffelb,AM DOO <br /> Ibsinacl $"D o <br /> VII.Responsibility Statement- 1,the undersigned,assume responsibility for installation of the PORTS shown an the attached plans. <br /> Plumber's Phone(Print) Plumber's Signe m e MP/MPRS Number Business Phone Number <br /> WADE RUFSHOLM `/(/, /. �s„ 227691 715-349-7286 <br /> Plumber's Address;(Street,City,State,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 <br /> eeeVAAdill.Coun /De artment Use Only <br /> W Date Iss <br /> Approved 0 Disapproved I'ermil Fee ucJ Issuing Agent Signature <br /> '1 f 37SJU Z-7-/H <br /> ❑Owner Given Reason for IXniel <br /> IX.Conditions of Approval/Reasons for Disapproval ECO <br /> E <br /> D JAN 3 2014 D <br /> An.mmmmpo-m prom mnbeswumand w6mbmma mann amy on rarer naaea� ban gt ernes In si.e <br /> BURNETT COUNTY <br /> ZONING i <br />