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`flalrrJlNp, Count <br /> %i o Safety and Buildings Division <br /> 1400 E Washington Ave SatutaryPertmtNumber(to be filled inbyCo.) <br /> Ps P.O.Box 7162 Sq r 1 )9 Cl <br /> Madison,WI 53707-7162 -T7 <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 requited prior to obtaining a sanitary permit. Note:Application forms for state-owned PO WTS 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. 1 m,Slats.I. Application Information-Please Print All Information -3/y <br /> -/ G co lo LK id <br /> Property Owner's Name Parcel#p 7 O/a :Z O C) <br /> OC�e- (90C) 0.;2 csnc7 <br /> Property Owner's Mailing Address Property Location <br /> ,29 Lt/ © L farrAllue F'e Govt.Lot <br /> City,S I late I Zip Code Phone Number y,, '/,, Section_L <br /> /� f r,e �,s 146olyo (circle one) <br /> T_2 O N; R %.'J— E a(W <br /> H.Type of Building(check all that apply) Lot# <br /> Vor 2 Family Dwelling-Number of Bedrooms y Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> El State Number State Owned-Describe Use ❑Village of <br /> V1 J65� wnof��,9 <br /> M.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' ❑New System l� lacement System <br /> y p y ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑ Change of Plumber ❑Permit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: Check all that a ] <br /> gNon-Pressurized In-Ground ❑ Pressurized In-Ground ❑At-Grade ❑Mound>24 is 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(sf) Dispersal Area Proposed(sf) System Elevation, <br /> 5 , 7 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units <br /> New Tanks Existing Tanks <br /> L m tC <br /> Septic or Baking-Tank <br /> Dosing Chamber 1 -T <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 n MPIMPRS Number Business Phone Number <br /> WADE RUFSHOLM /fl/1 y C� 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) !� /G <br /> PO BOX 514,SIREN,WI 54872 <br /> VM.County/Department Use Only <br /> Approved ❑ Disapproved Permit Fee O Date Issued Issuing Agent Signa e <br /> ElOwner Given Reason for Denial $ 37s1% 171 'A -Lu--A*-� <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> n E%C%;EIVE Fn) <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 xhil in ta"AUG <br /> L 2017 0 <br /> SBD-6398(R0313) BURNETT COUNTY <br /> ZONING <br />