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�eTii:. <br />� 4' ` <br />Safety and Buildings Division <br />County <br />16 ti I^,A <br />Sanitary Permit Number (to be filled in by Co.) <br />;; /� 0 „�• <br />1400 E Washington Ave <br />ON COMPUTE <br />S <br />S P.O. Box 7162 <br />�v <br />XCANNED <br />��; <br />Madison, WI 53707-7162 <br />� <br />�' <br />J� <br />SlErini� <br />Sanitary Permit Application <br />State Transaction Number <br />In accordance with SPS 38321(2), Wis. Adm. Code, submission of this form to the appropriate governmental unit <br />Note: Application farms for state-owned POWTS are submitted to <br />Project Address (if different than mailing address) <br />is required prior to obtaining a sanitary permit. <br />the Department of Safety and Professional Services. Personal information you provide may be used for secondary <br />in accordance with the Privacy Law, s. 15.04(1)(m), Stats. <br />/ apurposes <br />7 i 5 7 C <br />P azcel # C> !'i dZ Q %6 02 <br />I. Application Information - Please Print All Information <br />Property Owner's Name <br />s 7.36 113Love-) <br />Property Owner' ailing Address <br />Property Location <br />] <br />�� CL �CS i ' ' "` ' <br />Govt Lot <br />y� y., Section '2 b <br />City, State <br />Zip Code <br />Phone Number <br />Jer ,7 <br />- <br />r <br />YS <br />(circle oneS), <br />T N; R 16- EorW) <br />II. Type of Building (check all that apply) <br />k1 or 2 Family Dwelling -Number of Bedrooms v� <br />Lot # <br />t <br />n Name <br />Subdiv/i74) <br />!! �" <br />�1 yE'/ <br />Block# <br />❑ Public/Commercial - Describe Use <br />/ 6 <br />❑ City of <br />`— <br />11State Owned - Describe Use <br />❑Village of <br />1 / <br />CSM Number <br />III. Type of Permit: (Check only one box on line A. Complete line B if applicable) <br />A. <br />❑ New System <br />Replacement System <br />❑ Treatment/Holding Tank Replacement Only <br />❑ Other Modification to Existing System (explain) <br />B• <br />EJ Permit Renewal <br />El Permit Revision <br />El Change of Plumber <br />❑ Permit Transfer to New <br />List Previous Permit Number and Date Issued <br />Before Expiration <br />Owner <br />/ 70 L. 10-7-75- <br />0-7-7SIV. <br />IV.T <br />e of POWTS S stem/Com onent/Device: Check all that apply) <br />'&Non -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) <br />Design Soil Application Rate(gpdsf) <br />Dispersal Area Required (st) <br />Dispersal Area Proposed (sf) <br />System Elevation <br />/7 <br />46 <br />VI. Tank Info <br />Capacity in <br />Total # of Manufacturer w <br />Gallons <br />Gallons Units S, 2 U <br />mCq <br />New Tanks Existing Tanks <br />2 0 i a <br />rn is C7 w <br />Septic or Holding Tank <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) <br />WADE RUFSHOLM <br />Plumber's Signature <br />/ _ )� <br />MP/MP RS Number <br />227691 <br />Business Phone Number <br />715-349-7286 <br />Plumber's Address (Street, City, State, Zip Code) <br />PO BOX 514, SIREN, WI 54872 <br />II. Coun /De artment Use Only <br />Approved <br />❑ Disapproved <br />Permit Fee _ <br />$ D <br />Date Issued <br />Issuing Agent 'gn <br />El Owner Given Reason for Denial <br />3 76 ' — <br />IX. Conditions of Approval/Reasons for Disapproval <br />�V E <br />i1 n <br />Attach to complete plans for the system and submit to the County only on paper not less than $ t!2 z it incljpze� <br />i i l ut;' u A 2017 <br />U) <br />U U <br />BURNETT COUNTY <br />