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. , � o <br />;u; <br />Safety and Buildings Division <br />county <br />Qtr Q <br />f fill <br />/ ,;i <br />o� <br />1400 E Washington Ave <br />Sanitary Permit Number (to be filled in by Co_) <br />Imo' <br />� <br />P.O. Box 7162 <br />i�� <br />Madison, WI 53707-7162 <br />Sanitary pest Application <br />State Transaction Number <br />/v <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 />the Department of Safety and Professional Services. Personal information you provide may be used for secondary <br />7 d d <br />purposes in accordance with the Privacy Law, s. 15.04(1)(m), Stats. <br />�1 <br />L Application Information - Please Print All Information <br />Owner's Name <br />✓ O , <br />Parcel # p 7— 6/8- vL^2 -" <br />Property <br />/ <br />Property Owner's Mailing Address v <br />Property Location G <br />C e AJ 'e <br />Govt Lot <br />��, /,ti Section 8 <br />City, State <br />Zip Code <br />Phone Number <br />(circle one <br />T—N; R 1� E o QJ <br />II. Type of Building (check all that apply) <br />Lot # <br />Subdivision Name <br />;�J or 2 Family Dwelling —Number of Bedrooms 117— <br />Block # <br />❑ Public/Commercial - Describe Use <br />^ <br />El city of <br />❑ State Owned - Describe Use —� <br />❑ Village of <br />CSMNumber <br />-7 �/y <br />V9 p2 / <br />;g Town of e/O"' 2) <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 />1B. ❑ Permit 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 of POV"S System/Component/Device: (Check all that apply) <br />❑ Non -Pressurized In -Ground ❑ Pressurized In -Ground ❑ At -Grade ❑ Mound _> 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil <br />AHolding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain) <br />V. Dis ersal/Treatment Area Information: <br />Design Flow (gpd) <br />Design Soil Application Rate(gpdsf) <br />Dispersal Area Required (sf) <br />Dispersal Area Proposed (sf) <br />System Elevation <br />VI. Wank Info <br />Capacity in Total # of Manufacturer <br />Gallons Gallons Unitsa 1, 0 �, o <br />at cC <br />New Tanks Fadsting Tasks o 2 2 Y <br />a U <br />69=1 -or Holding Tank <br />QO 0 7s -U <br />Dosing Chamber <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 />WADE RUFSHOLM <br />Plumber's Signature <br />y <br />G{/ � , <br />MP/MPRS Number <br />227691 <br />1 <br />Business Phone Number <br />715-349-7286 <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 />❑Disapproved <br />Permit Fee <br />Date Issued <br />Issuing Agent Signature <br />ElOwner Given Reason for Denial <br />$Od <br />3 7 <br />7 %0 " <br />DL Conditions of Approval/Reasons for Disapproval <br />EC= W= <br />n� <br />Attach to complete plans for the system and submit to the County only on paper not less than IT <br />x <br />r7ljCeo A 2018 <br />U) <br />BURNETT COUNTY <br />