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/�,�Y�RT+!isur... <br />Safety and Buildings Division <br />County <br />u r/l1'e <br />1400 E Washington Ave <br />P.O. Box 7162�;_�� <br />Sanitary Permit Number (to be filled in by Co.) <br />Madison, WI 53707-7162 <br />Sanitary Permit Application <br />State Transaction Number <br />/,//I —� <br />In accordance with SPS 383.21(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 />purposes in accordance with the Privacy Law, s. 15.04 1 m , Stats. <br />% G <br />I. Application Information - Please Print All Information <br />Property Owner's Name <br />Parcel # O 7 002 <br />,J -0 A) fi <br />v?`% 5 o S ©o <br />dre <br />Add <br />Property Owner's Mail70P,J <br />Property Location <br />6 �/ S <br />Govt. Lot _ <br />y,, %., Section <br />City, State <br />Zip Code Phone <br />Number <br />/ CTj4� <br />n <br />6013 7 <br />/� rl :35 `555; <br />�� (,[circle one <br />T _Z N; R E o� <br />H. Type of Building (check all that apply) Lot <br /># <br />Subdivision Name <br />or 2 Family Dwelling - Number of Bedrooms <br />C Block <br />r <br />'- <br /># <br />❑ Public/Commercial - Describe Use <br />-- ' <br />❑ City of <br />CSM <br />❑ State Owned - Describe Use.- <br />❑ Village of <br />Number <br />V 7 // <br />G <br />-Town of ��� <br />III. Type of Permit: (Check only one box on line A. Complete line B if applicable) <br />`4' <br />❑ New System <br />y <br />�R pacement System <br />a lS <br />/❑ <br />❑ Treatment/Holding Tank Replacement Only <br />❑Other Modification to Existing System (explain) <br />B. <br />❑ 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 />r� A/V 6111A <br />IV. Type of POWTS 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 />❑ Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain) <br />V. Dispersal/Treatment Area Information: <br />Design F w (gpd) <br />Design Soil Application Rate(gpdsf) <br />Dispersal AreaRequired(so <br />Dispersal Area Proposed (sf) <br />System Elevation <br />ZJA0 <br />s } <br />�� v <br />C74 <br />VI. Tank Info <br />Capacity in <br />Total <br /># of Manufacturer <br />o <br />Gallons <br />Gallons <br />Units a <br />c <br />" <br />m <br />Existing Tanks <br />New Tanks <br />aU <br />nn A w0 <br />Septic or H@idnTzFwk <br />©Op <br />�� <br />/ � rZ J es c cf) <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 />Plumber's Signature <br />MP/MPRS Number <br />Business Phone Number <br />WADE RUFSHOLM <br />/` _ j <br />227691 <br />715-349-7286 <br />Plumber's Address (Street, City, State, Zip Code) <br />PO BOX 514, SIREN, WI 54872 <br />)VJMHII. Count /De artment Use Only <br />roved <br />�pp <br />❑ Disapproved <br />Permit Fee 00 <br />$ <br />Date Issued <br />Issuing Agent Signa e <br />�; <br />❑ Owner Given Reason for Denial <br />7S <br />37-5-'— <br />IX. Conditions of ApprovaVReasons for Disapproval <br />IX. <br />PROVED �a <br />Ek`.';`EV E R <br />Attach to complete pians for the system ano suotmt to me a.ounty onty on p:.per . .cs .an 0 0' , I. ...... <br />— "' '— <br />SBD -6398 (R0313) AUG U 7 2018 IU <br />BURNETT COUNTY <br />7nNlNr; <br />