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liee+rir`aiNy Countyp <br /> , � 0, , Safety and Buildings Division r,4J <br /> ON COMPU ER/SCAN �jWashington Ave Sanitary Permit Number( be filled in by Co.) <br /> Box 7162 ��[TJ LLI[I i <br /> Madison,WI 53707-7162 C"� / _�� <br /> rw1' J N <br /> Sanitary Permit Application State Tr apnsac(0/6'umber <br /> In accordance with SPS 38321(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit 12 o /a <br /> is required prior to obtaining a sanitary permit. Note:Application farms 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. 1 m Stats. <br /> I. Application Information-Please Print All Information <br /> Pro O er's Name Parcel#Q a 3 p2 3 7 /,Y O 3ra Ljzu� tiffs f ON va oilona <br /> Property O 's Mailing/Address Property Location <br /> /;?0 ///' Al Govt.Lot <br /> City,State Zip Code Phone Number C 1/y$ %, Section <br /> Gr,,4 s��, w� �> y� (circle one <br /> !O <br /> II.Type of Building(check all that apply) Lot# T-37 N; R E oCV <br /> *or 2 Family Dwelling-Number of Bedrooms <br /> �— Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use -- <br /> ❑ City of <br /> CSM Number ❑ Village of <br /> ElState Owned-Describe Use �— <br /> -P,Town of Tl- e- 'oe� ,--- <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A- ❑New System Replacement System &ITreatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal El Permit Revision ❑ Change of PlumbeTOwner <br /> mit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration <br /> IV.Type of POWTS S stem/Coro onent(Device: Check all that apply) <br /> ❑Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑Mound>24 in.of suitable soil Dkound<24 in.of suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Inf rmation: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(st) Dispersal Area:Proposed(st) System Elevation <br /> ys--/ y5dys-a9�,9 <br /> VL Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units ,�, I j g .2 <br /> New Tanks Existing Tanks <br /> �t a U rn q [a. C7 P. <br /> Septic or NoWnrg'mhk �/ <br /> Dosing Chamber r5 0 <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�ign re 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,SIREN,WI 54872 <br /> VIEL County/Department Use Onl <br /> Approved El Disapproved Permit Fee O Date Issued Issuing Agent Sign re <br /> ❑ Owner Given Reason for Denial $ 3��' t7 /02- - / <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> E C E 0 <br /> D <br /> Attach to complete plans for the system and submit to the County Only on paper not has than 8 112 z 'ach in$' V 2 n 2 16 <br /> - -_ BURNETT COUNTY <br /> ZONING <br />