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/4P,1fiTA(f,;� <br />Safety and Buildings Divisionc�r'� <br />County <br />1400 E Washington Ave <br />Sanitary Permit Number (to be filled in by Co.) <br />S. �� P.O. Box 7162 <br />`= ON C <br />v "✓ <br />MPUTEFd,%ffV07-7162 <br />/ <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 />Project Address (if different than mailing address) <br />is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are submitted to <br />be for <br />the Department of Safety and Professional Services. Personal information you provide may used secondary <br />purposes in accordance with the Privacy Law, s. 15.04(1)(m), Stats. <br />/ Of - <br />% `_'0 j L r <br />/ <br />Parcel # 0 7 poi d 6 �3 <br />I. Application Information — Please Print All Information <br />Pro erty Owner's Name <br />C1 C �/l�»✓1 SOS <br />�G75 f3 Cscf G/�/Ofd <br />Property O is Mailing Addres <br />Property Location G <br />, , C i e__ 4w L AJ <br />Govt. Lot <br />�/. '/4, Section 3- <br />City, State <br />Zip Code <br />Phone Number <br />p4gl <br />/ /" <br />/ 9 <br />(circle on <br />T � N; R � E oGW <br />H. Type of Building (check all that apply) <br />Lot # <br />Subdivision Name <br />11 or 2 Family Dwelling — Number of Bedrooms <br />Block # <br />_ <br />❑ Public/Commercial — Describe Use <br />❑ City of <br />❑ State Owned — Describe Use <br />❑ Village of �! <br />-Town of <br />CSM Number <br />��L f I <br />l <br />III. Type of Permit: (Check only one box on line A. Complete line B if applicable) <br />A/J4 <br />New System <br />❑ Replacement System <br />Treatment/Iolding Tank Replacement ment OnlY <br />❑ Other Modification to Existing System (explain) <br />B. <br />ElPermit Renewal <br />Permit Revision <br />❑ Change of Plumber <br />❑ 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 appi <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 (sf) <br />Dispersal Area Proposed (st) <br />System Elevation <br />VI. Tank Info <br />Capacity in Total # of Manufacturer <br />Gallons Gallons Units U �, y U <br />New Tanks Existing Tanks 10- <br />L) U w t7 p <br />i eplo"r Holding Tank <br />a <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) <br />WADE RUFSHOLM <br />Plumber's Signature <br />MP/MPRS Number <br />227691 <br />Business Phone Number <br />715-349-7286 <br />7y— <br />Plumber's Address (Street, City, State, Zip Code) <br />PO BOX 514, SIREN, WI 54872 <br />VIII. County/Department Use Only <br />Approved <br />❑ Disapproved <br />Permit Fee0 <br />$ D <br />Date Issued <br />ry <br />Issuing Agent Sign <br />El owner Given R on for Denial <br />/%S , <br />376- <br />/ <br />IX. Conditions of Approval/Re ons for approval <br />P� rrr►� Re ✓isioiv a000}�, % �t DECEIVE <br />/1%vNof-S,ys�m % le .lfnls�aG%d, <br />nn <br />OCT 0 2 11,7 <br />Attach to complete plans for the system ana suu ut to Toe a,ounry only on paper not less luau o 1- a , ■ .tea ucr... -.w LZ -7/ J <br />BURNETT COUNTY <br />ZONING <br />