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ty r r;it <br />County <br />-` ; • <br />Safety and Buildings Division <br />�'. <br />1400 E Washington Ave <br />Sanitary Permit Number (to be filled in by Co.) <br />P.O. Box 7162 <br />N _ .2j $ i'tg-7-7 <br />Madison, WI 53707-7162 <br />Sanitary Permit Application <br />State Transaction Number <br />In accordance with SPS 383.21(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. I5.04 1 m), Stats.% <br />- <br />II. Application Information - Please Print All Information <br />Property Owner's Name <br />Parcel # 0 7 0 f '� o2 y© S <br />i'S C_ <br />—0` - a C, <br />Property Owner's Mailing Address <br />� <br />� <br />Property Location !,o G j <br />- 6 �/L/ 5' <br />Govt. Lot � <br />/4j %4, Section <br />one <br />City, State <br />t <br />Zip Code Phone <br />•-7n <br />Number <br />vrJ"� <br />/ <br />/- `(circle <br />T —�- N; R / E or <br />i11. Type of Building (check all that apply) Lot <br /># <br />Subdivision Name <br />sl or 2 Family Dwelling - Number of Bedrooms <br />Block <br /># <br />❑ Public/Commercial - Describe Use -_- <br />�_ <br />�- <br />❑ City of <br />❑ State Owned -Describe Use CSM <br />❑ , - <br />Village of /� d <br />'Town <br />Number <br />i f / �' 5— <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 />P Replacement System <br />❑ Treatment/Holding Tank Replacement Only <br />El Other Modification to Existing System (explain) <br />• <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 />TV. Type of POWTS S stern/Conn onentI Device: Check all that apply) <br />Non -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) <br />System Elevation <br />Vl. Tank Info <br />Capacity in <br />Total <br /># of <br />Manufacturer <br />° <br />Gallons --� <br />Gallons <br />Units <br />°n <br />New Tanks <br />Existing Tanks <br />o <br />a U <br />n 5 <br />y <br />w <br />wC7 <br />P, <br />Septic or Iiwa-p i-lAr <br />I <br />(i j� C� <br />�i,� <br />_) <br />/v iJ r e j e-- <br />lt` <br />Dosing Chamber <br />VIE. Responsibility Statement- 1, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. <br />Plumber's Name (Print) <br />WADE RUFSHOLM <br />Plumber's Signature /3 <br />�/ #,, ­oe <br />MP/MPRS Number <br />227691 <br />Business Phone Number <br />715-349-7286 <br />Plumber's Address (Street, City, State, Zip Code) <br />PO BOX 514, SIREN, WI 54872 <br />VVIIIII. Coin /IIDe artnnent Use Only <br />Approved <br />El Disapproved <br />Permit Fee <br />$3 <br />Date Issued <br />Issw/ng A�ent S/igma e <br />❑ Owner Given Reason for Denial <br />/ <br />`' <br />EX. Conditions of Approval/Reasons for ➢Disapproval <br />((�� ��aa � /� Lon dc^ �r:t5 GXl � S �f.0 C" � V E <br />_nPAP, <br />Attach to complete plans 8or an suomr ro rntz- only u , Paper um leas uran o I as p*...w...-�.— <br />SBID-6398 (R0313) / d- u ILI,BURNETT COUNTYI�I__JJi <br />3 _/ 1, ZONING <br />