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r1�PA0.7'uF,yT County <br /> Safety and Buildings Division y/�All <br /> i $ 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> P.O. Box 7162 <br /> P Sr Madison,WI 53707-7162 -� r/ <br /> s n <br /> SanitaryiPermit Application Transaction Number <br /> In accordance with SPS 38321(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit 2072 7118 <br /> is required prior to obtaining a sanitary permit. Note:Application forms for state-owned POWTS are submitted to Project Address(if different than mailing addree S) <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. 15.04(1)(m,Stats. <br /> 1. Application Information-Please Print All Information Ac-c <br /> Ay <br /> Property Owner's Name Parcel# 0 7 0,2 <br /> ' c�/i cOoa <br /> 00 00 <br /> Property Owner's Mailing Address / �i / Property Location ,9 c- <br /> / <br /> Y33o GLS�4 L ^ �o/ Govt.Lot—3 <br /> Ci Stat Zi Code Phone Number /� <br /> t3'> p /., Section 3 <br /> (circle one <br /> H.Type of Building(check all that apply) Lot# T�N; R l6 E o <br /> ❑ 1 or 2 Family Dwelling—Number of Bedrooms Subdivision Name <br /> n Black# <br /> $.public/Commercial-Describe Use t/ G M� ❑City of <br /> ❑State Owned-Describe Use r <br /> SM Number ❑ Village of d <br /> 9-Town of © /r /3-/O <br /> 111.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. yNew System I ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal 11 Permit Revision 11 Change of Plumber El Permit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS S stem/Com onent/Device: Check all that apply) <br /> ❑ Non-Pressurized In-Ground ❑Pressurized In-Ground ❑ At-Grade YMound?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(sf) Dispersal Area Proposed(sf) System Elevation <br /> y0o 117, �4 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units <br /> New Tanks Existing Tanks <br /> &U ZZ w C7 W <br /> Septic or Holdiegfank <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(Print) Plumber's e 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.Coun /De artment Use Only <br /> Approved ❑ Disapproved Permit Fee <br /> ' O Date Issued Issuing Agent Signature <br /> ❑ Owner Given Reason for Denial $3�r' <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> ECE_WE �)) <br /> Attach�tn ompkte plans for the system and submit to the County only on paper not less than 8 In x In size <br /> FEB 18 2015 <br /> BURNETTCOUNTY <br /> ZONING <br />