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County <br />Safety and Buildings Division <br />=N `iy <br />1400 E Washington Ave <br />Sanitary Permit Number (to be filled in by Co.) <br />P.O. Box 7162 <br />Madison, WI 53707-7162 <br />01�IR5Q <br />`t <br />Sanitary Permit Application <br />State Transaction Number <br />In accordance with SPS 383.21(2), Wis. Adm. Code, submission of tins 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 PO WTS 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 />I. Application Information - Please Print All Information <br />Prop/{e/rrty Owner's <br />Parcel # � C <br />tName /�^^�� <br />q/ <br />q <br />Property Owner's Mailing Address �1 <br />/e'-d A <br />Property Location # 33 8 7 d <br />Vj 5 � / <br />/ �f /� L/ <br />Govt. Lot <br />/4, /4, Section <br />City, State <br />Zip Code Phone <br />Number <br />�6q" �j� <br />7 t Gi �j <br />rj -- G aT <br />, (circle one) <br />T �r`)°) N; R ��? E or W <br />II. Type of Bu ding (check all that apply) Lot <br /># <br />Subdivision Name <br />191, or 2 Family Dwelling -Number of Bedrooms <br />Block <br /># <br />❑ Public/Commercial - Describe Use <br />❑ City of <br />❑ State Owned - Describe Use —` CSM <br />Village of <br />Number <br />4❑ <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 />❑Replacement System <br />�Treatment/Holding Tank Replacement Only <br />El 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 />ANon -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/Treat ent 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 <br />Manufacturer <br />Y <br />°o b„ <br />Gallons <br />Gallons <br />Units <br />s, °' <br />New Tanks <br />Existing Tanks <br />y o <br />a U <br />vz y <br />Cn <br />a T <br />i... C7 <br />c`no <br />P, <br />Septic or H018 6� <br />4^ 000 <br />G/�{ > <br />t 'a a "' ' C ', <br />Dosing Chamber <br />VII. Responsibility Statement- I, 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 />Approved <br />❑ Disapproved <br />Permit Fee <br />Date Issued <br />Issuing Algen%t Si tur <br />r <br />$ 3-7-5- <br />q <br />/ / <br />❑ Owner Given Reason for Denial <br />!mot/ <br />IX. Conditions of Approval(Reasons for Disapproval <br />D <br />ORIGINAL.ini <br />Attach to complete plans for m stem anu suomn to me wur ny If paper nor 1- nNAIN o ./A 4, sr� ILA <br />/, <br />SBD-6398 (R0313) � A— �G ��CL <br />!L 1 �f 1+� U <br />Burnett County <br />Land Services Department <br />