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ORIGINAL <br />BURNETT COUNTY <br />Count <br />` <br />Safety and Buildings DivisionAt <br />D <br />IN! <br />1400 E Washington Ave <br />Sanitary Permit Number (to be filled in by Co.) <br />-�$p <br />P.O. Box 7162 <br />-`->f\�; - <br />=! <br />Madison, WI 53707-7162 <br />Sanitary Permit Application <br />State rafnsactionNumber <br />.T,� <br />In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental unit <br />/ ,4— <br />1/ <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 />a y .i <br />oses in accordance with the Privacy Law, s. 15.04 1 m , Stats. <br />` <br />I. Application Information - Please Print All Information <br />Property Owner's Name <br />Parcel # & -7-©3 Z-y� <br />Property Owner's Mailing Address <br />Property Location <br />-�- <br />3 J L i- k e- 5 / '�/' j ^'' <br />Govt. Lot _ <br />/4, Section -16 <br />le one)/T <br />City, State <br />Zip Code <br />C� Phone <br />Number <br />Z7e �yAv <br />� <br />N; RA!EorW <br />II. Type of Building (check all that apply) Lot <br /># <br />Subdivision Name <br />—11 <br />V-11 or 2 Family Dwelling - Number of Bedrooms <br />' <br /># <br />Block <br />❑ Public/Commercial - Describe Use —` <br />❑ City of <br />❑ State Owned - Describe Use CSM <br />❑ Village of �— <br />Town of <br />Number <br />1 % / P / <br />e, <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 />0 Other Modification to Existing System (explain) <br />B. <br />❑ Permit Renewal <br />❑ Permit Revision <br />❑ Change of Plumber <br />❑ Permit Transfer to New <br />Owner <br />List Previous Permit Number and Date Issued <br />�/✓- <br />Before Expiration <br />IV. Type of POWTS S stem/Com onent/Device: Check all that apply) <br />XNon -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) <br />Design Soil Application Rate(gpdsf) <br />Dispersal Area Required (sf) <br />Dispersal Area Proposed (sfJ <br />System Elevation <br />3Po <br />, �7 <br />y � <br />�s o <br />VI. Tank Info <br />Capacity in <br />Total <br /># of Manufacturer <br />c ° <br />Gallons <br />Gallons <br />Units <br />New Tanks <br />Existing TanksC <br />d y <br />a`, U n H yr <br />s a <br />w C7 a. <br />Septic or4Wd+e+m+k <br />/ <br />l <br />_� <br />�� <br />(1eA) E <br />-C:D <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 A <br />MP/MPRS Number <br />Business Phone Number <br />WADE RUFSHOLM <br />/CtC.Ca.✓ rr�- <br />227691 <br />715-349-7286 <br />Plumber's Address (Street, City, State, Zip Code) <br />PO BOX 514, SIREN, WI 54872 <br />VIII. Count /De artment Use Only <br />Approved <br />❑ Disapproved <br />�'376--- <br />Permit Fee G <br />490 <br />Date Isssued <br />Issuing Agent Signature <br />�)J <br />Q' <br />❑ Owner Given Reason for Denial <br />IX. Conditions of Approval/Reasons for Disapproval <br />APPROVED <br />Attach to complete plans for the system and submit to the County only on paper not less than 8 x 1 <br />SBD -6398 (R0313) <br />` �', AUG 13 2018 <br />L Ll <br />BURNETT COUNTY <br />