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Safety and Buildings Division <br />County <br />�. 7 <br />/ • ,�, 1400 E Washington Ave <br />' S <br />Sanitary Permit Number (to be filled in by Co.) <br />== �J1 P.O. Box 7162 <br />S <br />Madison, WI 53707-7162 <br />b o �� 1-7 <br />Sanitary Permit Application <br />State Transaction Number <br />-,1�3og 79V6 <br />In accordance with SPS 38321(2), Wis. Adm. Code, submission of this font to the appropriate governmental unit <br />is required to obtaining a sanitary permit Note: Application forms for state-owned POWTS are submitted to <br />Project Address (if different than mailing address) <br />prior <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()(m), Stats. <br />108,111 <br />_ <br />Parcel # ,- p �- 357-17-'12 <br />I. Application Information - Please Print All Information <br />Property Owner's Name / <br />7- 6 <br />'C.r1,\ C/ Je <br />4l C2 20ae1200 <br />Property Owner's Mailing Address <br />Property Location <br />� o <br />Govt. Lot <br />1/4, Section 1*1 <br />14-1 <br />City, State <br />Zip Code <br />Phone Number <br />��/ <br />circle one <br />T ��/N, R <br />II. Type of Building (check all that apply) <br />Lot # <br />� <br />Subdivision Name <br />r 2 Family Dwelling -Number of Bedrooms <br />[[l <br />Block;1 <br />D City of <br />❑ Public/Commercial - Describe Use r <br />❑ State Owned - Describe Use <br />❑ Village of �^ <br />�KTownof Z-//AGO/f-✓ <br />CSM Number <br />�— <br />III. Type of Permit: (Check only one box on line A. Complete line B if applicable) <br />A. <br />D New System <br />9�9eplacement System <br />D Treatment/Holding Tank Replacement Only <br />D Other Modification to Existing System (explain) <br />13• <br />❑ Permit Renewal <br />D Permit Revision <br />D Change of Plumber <br />D Permit Transfer to New <br />List Previous Permit Neumber and Date Issued <br />Before Expiration <br />Owner <br />%/OD <br />IV. Type <br />of POWTS S stem/Com onent/Device: Check all that apply) <br />D Non -Pressurized In -Ground D Pressurized In -Ground D At -Grade D Mound > 24 in_ of suitable soil Mound < 24 in. of suitable soil <br />D Holding Tank D 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 (sf) <br />Dispersal Area Proposed (sf) <br />SystemElevation <br />VI. Tank Info <br />Capacity in <br />Total <br /># of Manufacturer <br />O <br />Gallons <br />Gallons <br />Units 2V <br />d y <br />W <br />New Tanks Extsung Tankso <br />Septic or Holding Tank <br />/ <br />Dosing Chamber <br />S'eP C <br />- <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 />Plumber's Signature <br />MP/MPRS Number <br />Business Phone Number <br />WADE RUFSHOLM <br />/ <br />GSC.-oG••G�- <br />227691 <br />715-349-7286 <br />Plumber's Address (Street, City, State, Zip Code) <br />PO BOX 514, SIREN, WI 54872 <br />VIII. Coon /De artment Use Only <br />Approved <br />❑ Disapproved <br />Permit Fee <br />o <br />'3737 <br />Issued <br />Issuing Agent Si <br />7v o <br />�%Date <br />f <br />❑ Owner Given Reason for Denial <br />v ' <br />` cn " <br />TX. Conditions of Approval/Reasons for Disapproval <br />nD"IE PV" <br />n <br />APR 9 0 gnm <br />Attach to complete plans for the system and submit to the County only on paper not less tha4l in 1 inches in size <br />BURNETT COUNTY <br />ZONING <br />