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Conn <br /> Hcahrn ..�\ A> ty <br /> Safety and Buildings Division <br /> 1400 E Washington Ave unitary Pe it be filled in by Co.) <br /> r $p s' `�� p w`� P.O.Box 7162 _6q �XJ <br /> �, (, `A�ejO� Madison,WI 53707-7162 —1-7 <br /> Sanitary Permit Application sraxeT a�ionNumber <br /> in accordance with SPS 38321(2),Wis_Adm.Code,submission of this form to the appropriate governmental unit <br /> is required prior to obtaining a sanitary permit. Note:Application fonts for state-owned POWTS are submitted to ject 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 PrivacyLaw,s. 15.04(1 m),Stats. a � Ca:ddc l <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel#© -7 4 Ya-77 / .-2 1 s, <br /> t ,Q /` o -5- 0QZ D ©d O <br /> Property Owner's Mailing Address Property Location <br /> S6 cd/t) V C Govt.Lot .3 <br /> City,State Zip Code Phone Number / y, %,, Section <br /> / , s � ✓� // (circle one <br /> T 3ZN; R_/9 Eo W <br /> 11.Type of Building(check all that apply) <br /> Lot# <br /> 01 or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Bloc # <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> i <br /> ❑State Owned-Describe Use CSM Number ❑ Village of t 41 ,-74, 0,Town of Tr74 -AKt-- <br /> M.Type of Permit: (Check only one boa on line A. Comp)6to line B if applicable) <br /> A. %lew System ❑ Replacement System ❑ Tr ent/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑Permit Revision Change of Plumber ❑Permit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Cramer <br /> IV.Type of POWTS S stem/Con onent/Dev- e: Check all that apply) <br /> ❑Non-Pressurized In-Ground ❑Pressurized round ❑At-Grade ❑Mound>24 in_of suitable soil ❑Mound<24 in.of suitable soil <br /> Holding Tank ❑Other Dispersal Comp t(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treat ent Area Informs on: <br /> Design Flow(gpd) Design Soil Appli on Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 3@e <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> w <br /> Gallons Gallons Units E o <br /> New Tanks' Existing Tanks o g a m <br /> U iz cn w C7 13, <br /> 4apeaorHolding Tank 7 a <br /> Dosing Chamber !J� <br /> V11.Responsibility tement-1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(P ' Plumber's Signature MP/MPRS Number Business Phone Number <br /> WADE RUFSHO / 1 r 227691 7I5-349-7286 <br /> -T <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX 514, WI 54872 <br /> V111.Co /De artment Use Only <br /> rApprd/,ed Disapproved Permit Fee ate ssuing Agm Sign re <br /> ❑ Owner Given Reason for Denial c3 75J 7-er o 1 <br /> DL Conditions of Ap/provaal/Reasons for Disapproval <br /> �1 / <br /> X,� �e,. /a �.v!✓�a?C 7 rI�vi iti� /� �/f dC [DIECUEOVE <br /> ni�Iv-'LL ,�c �/•t•�✓ ,Qrrrt wa� . JUL 2 0 <br /> 2017 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 1 lacbemn size <br /> BURNETT COUNTY <br /> ZONING <br />