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�v5ramr.4FyT Comity - <br /> ?w Safety and Buildings Division <br /> 1.400 E Washington Ave Sanitary Permit <br /> /Number(to be filled in by Co.) <br /> 1 3 ps P.O. Box 7162 <br /> Madison,WI 53707-7162 —IL LT <br /> ` <br /> Sanitary Permit Application State Tnia action Number <br /> In accordance with SPS 3832](2),Wis.Adm.Code,submission of this form to the appropriate governmental unit <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 address) <br /> the Department of Safety and Professional Services. Personal information you provide may he used for secondary <br /> puToses in accordance with the Privacy Law,s.15.04(1)(m),Stars. <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# O -7 Q O 6 <br /> 0 ✓ e /Yl 0-5,001 p /O , <br /> Property Owner's Mailing Address Property Location ,)`1 <br /> 0-5- a/ L k, G'I Govt.Lot_L_ <br /> City,State Zip Code Phone Number y4, /<, Section-Z-7— <br /> 5 ¢7a (circle one <br /> II.Type of Building(check all that apply) o tot 9 T_ N, R�_7__E o R` <br /> I-I or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> -� Block# <br /> ❑Public/Commercial-Describe Use <br /> - ❑ City of <br /> ' <br /> ❑State Owned-Describe Use CSM Number El viIlage of ll <br /> Town of /t)i e 1 S <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' ❑New System $eplacement System �Treatment/Holdmg Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑Pemit Renewal ❑Permit Revision ❑Change of Plumber <br /> ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: Check all that apply) <br /> ❑ Non-Pressurized In-Ground ❑ Pressurized Tri-Ground ❑At-Grade ❑Mound_>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> Molding 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(sl) Dispersal Area Proposed(A) System Elevation <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o <br /> New Tanks Existing Tanks w e 0 = <br /> 0 <br /> Saptmor Holding Tank <br /> t7r �� Irl <br /> Dosing Chamber <br /> VIL Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Si ature MP/MPRS Number Business Phone Number <br /> WADE RUFSHOLM f_ i 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 <br /> VIII.County/Department Use Only <br /> Approved ❑Disapproved Permit Fee Date Issued Issuing ent 'gnature <br /> O _ r <br /> $ <br /> 11Owner Given Reason for Denial �7� ' -� 7-i5 �(Q 1✓lJtia� <br /> M Conditions of ApprovaVReasons for Disapproval Rai, <br /> E C Lit LJ E <br /> JUL 15 2016 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 9 12 z in sift <br /> BURNETTCOUNTY <br /> ZONING <br />