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Attach to complete plans for the system and submit to the County only on paper not cess man b x A t3ncues rn . r„1 <br />BURNETT COUNTY <br />ZONING <br />County <br />Safety and Buildings Division <br />,�g" e—( r <br />j}r; 1400 E Washington Ave <br />Sanitary Permit Number (to be filled in by Co_) <br />== lj P.O. Box 7162 <br />Madison, WI 53707-7162 <br />�rf0� <br />s ` <br />O ->-I 4 <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 unlit <br />is to a sanitary Note: Application forms for state-owned POWTS are submitted to <br />Nq � <br />Project Address (if different than mailing address) <br />required prior obtaining permit <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 />Pazcel # p % O <br />L Application Information – Please Print All Information <br />Property Owner's Name <br />0050- <br />�/ M J��ti�o J <br />soy- a,?000o <br />Property Owner's Mailing Address <br />Property Location <br />C� G Z /� f� /� k� <br />Govt Lot <br />�/, '/4, Section <br />City, State <br />Zip Code�y� <br />Phone Number <br />(� <br />crrcle on <br />T 3� N; REo PW <br />H. Type of Building (chd& all that apply) <br />Lot # <br />Subdivision Name <br />1X1 or 2 Family Dwelling – Number of Bedrooms 1-�-'11 <br />Block # <br />❑ City of �— <br />❑ Public/Commercial – Describe Use <br />❑ State Owned – Describe Use �– <br />❑ Village of p <br />ZTown <br />CSM Number / <br />of <br />111. 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 />16- <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 />IV. Type of POW R'S S stem/Com onentJDevice: Check all that ap 1 <br />5(N.. -Pressurized ln-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. Dis ersal/Treatrttent Area Information: <br />Design Flow (gpd) <br />Design Soil Application Rate(gpdst) <br />Dispersal Area Required (st) <br />Dispersal Area Proposed (sf) <br />System Elevation <br />3Oy <br />VI. Tank Info <br />Capacity in <br />Total <br /># of Manufacturer <br />o <br />Gallons <br />Gallons <br />Units vY '3 <br />New Tanks Existing Tanks <br />o 2 i <br />a U n rn is. C7 is <br />Septic or Ho>dittg4auk <br />Dosing Chamber <br />VII. Responsibility Statement- A, 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 />227691 <br />715-349-7286 <br />Plumber's Address (Street; City, State, Zip Code) <br />PO BOX 514, SIREN, WI 54872 <br />Coun /De artment Use Only <br />9 Approved <br />El Disapproved <br />.Permit Fee <br />$ <br />Date Issued <br />Issuing Agent Sign <br />ElOwner Given Reason for Denial <br />3 7y' <br />- a a - 18' <br />11 Conditions of. Q.pproval/Reasons for Disapproval <br />V <br />n <br />LJ <br />APPROVED nn <br />Y Z 2 2018 <br />Attach to complete plans for the system and submit to the County only on paper not cess man b x A t3ncues rn . r„1 <br />BURNETT COUNTY <br />ZONING <br />