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BURNETT COUNTY <br />ZONING <br />Buildings Division <br />County <br />Safety and <br />0 'i'^,• <br />1400 E Washington Ave <br />Sanitary Permit Number (to be filled in by Co.) <br />S �. H, <br />P.O. Box 7162 <br />6AN,1`$- <br />Madison, WI 53707-7162 <br />S 2 <br />/ <br />Sanitary Permit Application <br />State Transaction Number� A <br />_ <br />In accordance with SPS 38321(2), Wis. Adm. Code, submission of this form to the appropriate governmental unit <br />Note: Application forms for state-owned POWTS are submitted to <br />Project Address (if different than mailing address) <br />is required prior to obtaining a sanitary 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 />`r .Q <br />�+OS e- C--/ <br />Parcel # e 7 OX O- ,; - V O- 2 <br />L Application Information - Please )Print All Information <br />Property Owner's Name <br />/ <br />V r P L- e- e, <br />S/ 5- 91 _?r-> Oa0 <br />Property Owner's Vailing Address <br />Property Location <br />©D 7`6 /'¢ C/ <br />Govt Lot <br />y, '/4, Section �D <br />City, State <br />ZipCode <br />Phone Number <br />7- <br />Ir e O � t--4- <br />/ <br />J5< D;7- [ <br />71•� 7F d —501 � <br />(circle one <br />T_�N; REo>�J <br />U. Type of Building (check all Haat apply) <br />Lot # <br />Subdivision Name <br />❑ 1 or 2 Family Dwelling -Number of Bedrooms Z <br />Block <br />❑ City Of �— <br />❑ Public/Commercial - Describe Use <br />7 <br />El State Owned -Describe Use <br />❑ Village of <br />- <br />CSMNumber <br />Town of L3 ,4t<1i <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 />B. <br />❑ Permit Renewal <br />El Permit Revision <br />11Change of Plumber <br />❑ Permit Transfer to New <br />List Previous Permit Number and Date Issued <br />Before Expiration <br />Owner <br />IV. Type of POWTS S stern/Com onent/Device: Check all that apply) <br />XNon-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(gpdst) <br />I Dispersal Area Required (st) <br />I <br />Dispersal Area Proposed (sf) <br />System Elevation <br />9�, / <br />o <br />z 1 <br />ly-S-0 <br />.3© <br />/-7 <br />VI. Tank Info <br />Capacity in <br />Total # of Manufacturer <br />O <br />Gallons <br />Gallons Units N y <br />m v U ,"1 <br />2 <br />m <br />New Tanks Existing Tanks <br />d o ? y a <br />a 0 E m 80 is., 0 <br />ii <br />Septic or g auk <br />/OO D <br />z / ,J n &,.jeS < a <br />' v <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 />oe227691 <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 />$ 3 <br />Date Issued <br />Issuing Agent Signature <br />❑ Owner Given Reason for Denial <br />7S- <br />9. Conditions of Approval/Reasons for ]Disapprove! <br />ECOVE <br />D <br />q[n:) <br />MAY 2 3 2018 <br />A— --A —1....it m them r —*W nnly nn rarer not tact than R 1/21 46.hiAin size <br />BURNETT COUNTY <br />ZONING <br />