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crsrira:' .f <br />Safety and Buildings Division <br />Coun <br />/ y �- <br />anitary Perm Number (to be filled in by Co.) <br />c� <br />1400 E Washington Ave <br />�,� S p �' !<� P.O. Box 7162 <br />� <br />\ 1 S Madison, WI 53707-7162 <br />9 L <br />\J <br />State Transaction Number <br />Sanitary Permit Application <br />In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental unit <br />forms for state-owned POWTS are submitted to <br />Project Address (if different than mailing address) <br />is required prior to obtaining a sanitary permit. Note: Application <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 />-31 ���'� 55 / Lod <br />I. A plication Information - Please Print All Information <br />paz1 # d " O � � v� / 1 <br />Property Owner's Name <br />5-05 0 l O 046 <br />Property Owner's Mailing Address <br />Property Location '10G <br />3 / <br />Govt. Lot <br />City, State l Zip Code Phone Number <br />y, '/4, Section <br />circle one <br />II. Type of Building (check all that apply) <br />Lot # <br />J <br />Subdivision Name <br />or 2 Family Dwelling - Number of Bedrooms -- <br />— <br />Block # <br />❑ City of <br />❑ Public/Commercial - Describe Use <br />-' <br />❑ Village of �— <br />CSM Number <br />❑ State Owned - Describe Use, <br />t // <br />` <br />Mown of � f <br />III. Type of Permit: (Check only one box on line A. Complete line B if applica le) <br />A. <br />❑ New System <br />replacement System <br />`<` �\` <br />❑ Treatment/Holding Tank Replacement Only <br />[I Other Modification to Existing System (explain) <br />B. <br />❑ Permit Renewal <br />C1 Permit Revision <br />[I Change of Plumber <br />El Permit Transfer to New <br />List Previous Permit Number and Date Issued <br />Before Expiration <br />Owner <br />IV. Type <br />of POWTS System/Component/Device: Check all that apply) <br />KNon-Pressurized In -Ground ❑ Pressurized In -Ground ❑ At -Grade ❑ Mound > 24 in. of suitable soil <br />❑ Mound < 24 in. of suitable soil <br />❑ Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain) <br />V. Dis ersal/Treatment Area Information: <br />Design Flow (gpd) Design Soil Application Rate(gpdst) Dispersal Area Required (sf) Dispersal Area Proposed (sf) System Elevation <br />VI. Tank Info Capacity in Total # of Manufacturer <br />Gallons Gallons Units o w U <br />New Tanks Existing Tanks <br />y <br />a. U Cn y CZ w C7 P <br />Septic or flelding-T=k <br />— AW o r a e] co <br />G� <br />/00P <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 (Print) Plumber's Signature / MP/MPRS Number Business Phone Number <br />1 227691 715-349-7286 <br />WADE RUFSHOLM <br />Plumber's Address (Street, City, State, Zip Code) <br />PO BOX 514, SIREN, WI 54872 <br />VIII. County/De artment Use Only <br />Approved <br />❑ Disapproved <br />Permit Fee <br />$ 0 <br />Date Issued <br />Issuing Agent Signatu <br />❑ Owner Given Reason for Denial <br />.�^ <br />37J ' <br />7-11-17. <br />IX. Conditions of Approval/Reasons for Disapproval <br />�® C E I <br />EAttach <br />�1' <br />RchE <br />to complete plans for the system and submit to the County only on paper not less than 8 t <br />BURNETT COUNTY <br />ZONING <br />