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.�fie�at�is`v.1 Coun _. <br /> Safety and Buildings Division � <br /> frf '' 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> 3s Sp P.O. 2 <br /> /JJ , <br /> Madison,WI1537053707-7162 <br /> AI <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 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.15.0 1 m,Stats. 2 <br /> L Application Information-Please Print All Information Parcel <br /> Property Owner's Name l Pazcel# p O 1/O ! O S <br /> ?CJ s PCO !� 00c7 <br /> Property Owner's Mailing Address Property Location <br /> e, J,+Ie, P(' Govt.Lot <br /> City,State Zip Code Phone Number y,, /. Section 7 <br /> e_u)P/f�� n t / / crrcle one <br /> riC /5 rel 3 b�� T N, R�E� <br /> H.Type of Building(che&all that apply) Lot# <br /> �I or 2 Family Dwelling-Number of Bedrooms �5/ Subdivision Name / (/ <br /> Block# <br /> ❑Public/Commercial-Describe Use ❑ City of e <br /> ❑State Owned-Describe Use CSM Number ❑ village of <br /> Town of se l <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑New System ❑Replacement System $greatrment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal 11Permit Revision ❑Change of Plumber [IPermit Transfer to New List Previous Permit Number and Date slued <br /> Before Expiration Owner 130- �-' _ <br /> IV.Type of POWTS System/Component/Device: Check all that apply) <br /> WNon-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑Mound>74 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) Design Soil Application Rate(gpdst) Dispersal Area Required(sl) Dispersal Area Proposed(sf) System Elevation <br /> 300 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units „ U d Y <br /> New Tanks Existing Tanks o y y 'aa <br /> Septic or l{aldsq-T�r d l] �- da o Fere eS ed <br /> Dosing Chamber <br /> VIL Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumbqrs Si ature MP/MPRS Number Business Phone Number <br /> WADE RUFSHOLM 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX 514,SMN,WI 54872 <br /> VIII.Cour /De artment Use Only <br /> Approved ❑Disapproved Permit Fee O Date Issued Issuing Agent Si e <br /> "g41_4,d,) <br /> ❑Owner Given Reason for Denial S27-57. I D <br /> DL Conditions of Approval/Reasons for Disapproval <br /> ECEovE <br /> 0%4%.r a A n <br /> Attach to complete plans for the system and submit to the County only on paper not Im than 8 t2 x 1 I Inch n <br /> --- ---- •-----• BURNE77COUNTY <br /> ZONING <br />