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Attach to complete plans for the system and submit to the County only on paper not less than 84a z JA inches in sae t v <br />^- - 13URNETT COUNTY <br />L_J <br />ZONING <br />County <br />`a_ 0,.. Safety and Buildings Division <br />;; ,� <br />�. <br />1 y ,fit 1400 E Washington Ave <br />Sanitary Permit Number (to be filled in by Co_) <br />P_O. Box 7162 <br />SAN <br />Madison, WI 53707-7162 <br />Uoss <br />CST 1$- <br />g� <br />Sanitary Permit .Application <br />State Transaction Number <br />In accordance with SPS 38321(2), Wis_ Adm. Code, submission of this form to the appropriate governmental unit <br />is to a sanitary Note: Application forms for state-owned POWTS are submitted to <br />IVA— <br />Project Address (if di$erent 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. 15.0 1 m), Stats. <br />Parcel # p -7- <br />I. Application Information - Please Print All Information <br />Owner's Name <br />Property <br />Property Owner's Mailing Address <br />Property Location <br />5 / 6 q 5 W,/ 7a <br />Govt Lot _.3 <br />'/S A Section <br />City, State <br />L� <br />Zip Code <br />Phone Number <br />/ , <br />(� 7 z <br />/ <br />yy �� <br />(circle on <br />T N, R�Ea <br />Il. Type of Building (check all that apply) <br />Lot # <br />Subdivision Name <br />,�I or 2 Family Dwelling -Number of Bedrooms <br />112 <br />Block # <br />❑ City of <br />❑ Public/Commercial - Describe Use <br />"-' <br />❑ State Owned - Describe Use <br />❑ Village of <br />PeTownofZ,-,j 2(e�/Jo ,J <br />CSM Number <br />V 1_/_1P 9a <br />III. Type of Permit: (Check only one box on line A. Complete line Rif applicable) <br />A. <br />❑ New system <br />XReplacernent System <br />❑ Treatment/Holding Tank Replacement Only <br />❑ Other Modification to Existing system (explain) <br />16• <br />11 Permit Renewal <br />❑Permit Revision <br />Change of <br />❑ Chan <br />El Transfer to New <br />List Previous Permit Number and Date Issued <br />Before Expiration <br />Owner <br />IV. Type <br />of POWTS S m/Com onent/Device: Check all that a l <br />on -Pressurized ln-Ground ❑ Pressurized In -Ground ❑ At -Grade ❑ Mound >24 ua of suitable soil ❑ Mound <24 in. o£suitable soil <br />❑ Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain) <br />V. Dis ersal/Treatment Area Information: <br />Design Flow (gpd) <br />Design Soil Application Rate(gpdsf) <br />Dispersal Area Required (st) <br />Dispersal Area Proposed (st) <br />System Elevation <br /><15-0e <br />41-3 <br />6 s <br />VI. Tank Info <br />Capacity in <br />Total <br /># of Manufacturer <br />C v <br />Gallons <br />Gallons <br />Units „ i <br />U <br />2 <br />New Tanks Sxostmg Tanks <br />y o <br />w 0 <br />va <br />ria u C7 P <br />Septic or XoldiWTm* <br />O O — <br />0� jf <br />�% B i�W 5 C o <br />Dosing Chamber <br />VH. Responsibility Statement- 1, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. <br />Plumber's Name (Print) <br />Plagnature <br />MP/MPRS Number <br />Business Phone Number <br />WADE RUFSHOLM <br />/ / <br />„`%2 <br />227691 <br />715-349-7286 <br />✓ <br />Plumber's Address (Street; City, State, Zip Code) <br />PO BOX 514, SIREN, W1 54872 <br />CountyADepartment Use Only <br />Approved <br />❑ Disapproved <br />Permit Fee O <br />$ <br />Date Issued <br />Lssuing Agent Sign <br />(� <br />11 Owner Given Reason for Denial <br />� 7S. <br />Vadi_ff� <br />R%. Conditions of ApprovaNReasons for Disapproval <br />1100 <br />PD � <br />nn <br />[] JUN 19 20 <br />Attach to complete plans for the system and submit to the County only on paper not less than 84a z JA inches in sae t v <br />^- - 13URNETT COUNTY <br />L_J <br />ZONING <br />