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r�FraF rArsti�� County <br /> Safety and Buildings Division /11 <br /> Je/t t7t1 <br /> = 4 ' ON COMPUTE SCANIVL�90 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> Sp s !`� P.O. Box 7162 <br /> =r' ` f�' Madison,WI 53707-7162 _ <br /> Sanitary Permit Application State Transaction Number <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 forms for state-owned POWTS are submitted to Project Address(if differentthan mailing adoress)i <br /> the Department of Safety and Professional Services. Personal information you provide may be used for secondary �� v /j)/C-K e y SrY1 j 1 <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. I.Dr K 6,JAW1 <br /> I. Application Information—Please Print All Information <br /> Property Owner's Name Parcel# 0 '7 0 eZ °/O <br /> Property Owner's Mailing Address Property Location /O C/ <br /> o l-d ,- L Govt Lot 3 <br /> City,State Zip Code Phone Number y, ' ,j:7j <br /> /., Section <br /> C� circle one) <br /> SIn AJ �// T `�L N; R l� E oit'OV) <br /> H. pl of Building(check all that apply) Lot# <br /> ❑ Subdivision Name <br /> 1 or 2 Family Dwelling—Number of Bedrooms <br /> Block# <br /> 9Public/Commercial—Describe Use L e— ' ❑City of <br /> El State Owned—Describe Use CSM Number ❑Village of /� <br /> To F�wn of 0 A if <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. New System ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B• ❑Permit Renewal El Permit Revision El Change of Plumber El Permit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS S stem/Coin onent/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/Treat eat Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> VI.'Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units „ ? U <br /> T-�H , <br /> New Tanks Existing Tankso ; rn <br /> .Sop6s or Holding Tank <br /> Dosing Chamber v <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plum er re MPIMPJS Number Business Phone Number <br /> 227691 <br /> WADE RUFSHOLM C/ y�-�, 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 <br /> VIII.Coun /De artment Use Onl <br /> Approved El Disapproved Permit Fee D0 Date Issued rsu� <br /> Si afore <br /> ElOwner Given Reason for Denial $ 37S 3 -7 <br /> IN.Conditions of Approval/Reasons for Disapproval <br /> EC;% EoVE <br /> Attach to complete plans for the system and submit to the County only on paper not less than 81/2 1 i es, 2011 Uj <br /> -- "-- "�'-"- BURNETT COUNTY <br /> ZONING <br />