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Safety and Buildings Division <br />County <br />1 -"'A) e <br />%! <br />��. 1400 E Washington Ave <br />Sanitary Permit Number (to be filled in by Co. <br />^� P.O. Box 7162 <br />5��.�(�.�Y <br />Madison, WI 53707-7162 <br />6OMq 9- <br />Sanitary Permit Application <br />State Transaction Number <br />Nfi <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 />purposes in accordance with the Privacy Law, s. 15.04(1)(m), Stats. <br />11 S / <br />Parcel # O � ��' <br />L Application Information - Please Print All Information <br />Property Owner's Name <br />Property Owner's Mailing Address <br />Location ,0 <br />p /Property <br />3 el 12.5— O I \ d LC'-/ .3 <br />Govt. Lot <br />1/4, /t; '/., Section> <br />City, State <br />Zip Code <br />Phone Number <br />G ! •� <br />S `��' <br />(circle one) <br />T S N; R / c� E 00) <br />II. Type of Building (c ck all that apply) <br />Lot # <br />Subdivision Name <br />or 2 Family Dwelling - Number of Bedrooms <br />Block # <br />❑ City of �- <br />❑ Public/Commercial - Describe Use <br />-- - <br />❑ State Owned - Describe Use J <br />❑ Village of <br />CSM Number <br />-" <br />g Town of Z d ,01 /1 'vim <br />lH. '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 />13. <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 POWTS System/Component/Device: Check all that apply) <br />9 Non -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 (sf) <br />System Elevation <br />VI. Tank Info <br />Capacity in <br />Total <br /># of Manufacturer <br />Gallons <br />Gallons <br />Units <br />s, ;? U <br />C2 <br />New Tanks <br />Existing Tankso <br />;? 2 y <br />a. U 55 H rn <br />Septic or iiokUagZank <br />U <br />�_ <br />L,Li <br />CJ t' Ct/ L G 0 <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 />Plumber's Signature <br />MP/MPRS Number <br />Business Phone Number <br />WADE RUFSHOLM <br />' / <br />227691715-349-7286 <br />Plumber's Address (Street, City, State, Zip Code) <br />PO BOX 514, SIREN, WI 54872 <br />H. Coun /De artment Use Only <br />Approved❑Disapproved Permit Fee Date Issued Issuing Agent Signature <br />$ '9-a <br />I% qJWq#Qiwrk n for Denial V / <br />IX. Co4rrffmtv for Disapproval <br />EEO V E <br />np rn <br />Attach to complete plans for the system and submit to the County only on paper not less than 8 W x 11 in es i <br />t MAY 6 zom 10 <br />r <br />BURNETT COUNTY <br />ZONING <br />