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Safety and Buildings Division <br />County <br />,&N/' e- <br />fl 1400 E Washington Ave <br />Sanitary Permit Number (to be filled in by Co. <br />;a; S� •' I-� P.O. Box 7162 <br />S r� tJ -1�-U"I <br />S,! i Madison, WI 53707-7162 <br />State Transaction Number <br />Sanitary Permit Application <br />/V/9 <br />In accordance with SPS 38321(2), Wis. Adm. Code, submission of this form to the appropriate governmental unit <br />Note: Application forms for state owned POWTS are submitted to <br />Project Address (if different than mailing aKddress)� <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 />purposes in accordance with the Privacy Law, S. 15.04(1)(m), Stats. <br />I. Application Information — Please Print All Information <br />Parcel # 0 7_ p 3 (>' <br />Property Owner's Name <br />pp <br />-6 0e>Q <br />l -G <br />Property Location <br />Property Owner's Mailing Address <br />5! Avc, <br />b <br />GovL Lot _ <br />City, State Zip Code Phone Number <br />%, '/4, Section 1,2_5 <br />! <br />1 % UC1 S C, "i et) -'r J_ � ©< b / 7 5 � — —7 35 <br />Mur <br />(circle o��neL <br />E > <br />T _� N; R � " <br />-1 Lot # <br />II. Type of Building (check all that apply) <br />or2Family Dwelling — Number ofBedrooms1;12� <br />Subdivision Name ! <br />L�k�s��� Lp4� <br />Block # <br />C_ 4 / ' <br />❑ City of —' <br />❑ Public/Commercial — Describe Use <br />^ <br />❑ Village of <br />CSM Number <br />❑ State Owned — Describe Use <br />r <br />� Town of 41/t.l ! 'O /J <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 />❑ Permit Renewal <br />❑ Permit Revision <br />❑ Chan ge of Plumber <br />❑ Permit Transfer to New <br />List Previous Permit Number and Date Issued <br />Before Expiration <br />Owner <br />106,76 S- y - 93 <br />W. Type <br />of POWTS System/Component/Device: Check all that a 1 <br />❑ Non -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. Dispersal/Treatment Area Information: <br />Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required (sf) Dispersal Area Proposed (sf) System Elevation <br />Q <br />VI. Tank Info <br />Capacity in <br />Total # of Manufacturer <br />°o b <br />Gallons <br />Gallons Units <br />s U ti <br />P? <br />New Tanks Existing Tanks <br />0 o <br />w U y rn ii C7 f? <br />Septic ori4oldiWTank <br />/ eq ©p <br />Dosing Chmber <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 7 /MPRS Number Business Phone Number <br />715-349-7286 <br />WADE RUFSHOLMR �• 1 227691 <br />�/ �c �/s y' — <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 <br />11 Disapproved <br />Permit Fee <br />$ <br />Date Issued <br />Issuing Agent Sign al- <br />3 75V <br />Q <br />3- Z 7— <br />❑ Owner Given Reason for Denial <br />0 <br />IX. Conditions of Approval/Seasons for Disapproval <br />//Z Z, ��t/xzZ sP/oa��, DECEIVE <br />R>o�I��ev�IPNr of �eeL /a.u1i �N� • <br />MAR .21 <br />Attach to complete plans for the system and submit to the County only on paper not less than 8 u2 1 i es in size <br />BURNETT COUNTY <br />ZONING <br />