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County <br />,..y, <br />Safety and Buildings Division <br />`ASP <br />1400 E Washington Ave <br />Sanitary Permit Number (to be filled in by <br />P.O. Box <br />'Co.)/ <br />M -t�_g7 <br />Madison, WI 53707-7162 <br />.. .sf.'c�•!{}�'•�ti:-`j <br />� •mil <br />Sanitary Permit Application <br />State Transaction Number <br />In accordance with SPS 383.21(2), Wis. Adm. Code, submission of t11is form to the appropriate governmental unit <br />is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are submitted to <br />Project Address (if different than mailing address) <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 />I. Application Information - Please Print All Information <br />Prop rty Owner's r Na e _ <br />�i4N <br />Parcel # © '7 c, _3 o? 37 19'� <br />A t� cE? <br />3 0 coo r //C10/0 32Lo <br />Property Owner's Mailing A ess P �( P <br />Property Location .!> C-/ <br />3 L <br />tJ �/' "� " <br />Govt. Lot <br />, X b <br />/�iGJ /<, Sep /a, Section <br />City, State <br />Zip Code <br />Phone Number <br />La K <br />(� 5 3 <br />circle one <br />T _37 N; R � E ora'L )V <br />H. Type of Building (check all that apply) <br />Lot # <br />(( or 2 Family Dwelling -Number of Bedrooms <br />Subdivision Name <br />Block # <br />❑ Public/Commercial - Describe Use �— <br />�- <br />❑ City of <br />❑ State Owned - Describe Use -� <br />❑ Village of <br />CSM Number <br />��- <br />III. Type of Permit: (Check only one box on line A. Complete line B if applicable) <br />A• <br />❑ New System <br />y <br />Re lacement System <br />p y <br />❑ Treatment/Holding Tank Replacement Only <br />❑Other Modification to Existing System (explain) <br />B. <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 <br />of POWTS System/Component/Device: (Check all that apply) <br />gNon-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(gpdsf) <br />Dispersal Area Required (sf) <br />Dispersal Area Proposed (sf) System <br />Elevation <br />Z/�o I <br />& S <br />:�� 79 <br />VI. Tank Info <br />Capacity in <br />Total <br /># of <br />Manufacturer <br />Gallons <br />Gallons <br />Units <br />New Tanks <br />Existing Tanks <br />o <br />y <br />D <br />a <br />U Z <br />w C7 <br />a <br />Septic or Holding Tank <br />7S U <br />Js <br />t <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 />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 />Xpproved <br />❑ Disapproved <br />Permit Fee` <br />Date Issued <br />Issuing ent Signature <br />$ / <br />7 <br />7 �� <br />E C MV <br />[I Owner Given Reason for Denial <br />✓ /' <br />v / <br />IX. Conditions of Approval/Reasons for Disapproval <br />JUN 17 2019 IU <br />BURNETT COUNTY <br />Attach to complete plans for the system and submi a r not less than 81/2 x 11 inchEsliitOiM U <br />SBD-6398 (R0313) <br />