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Safety and Buildings Division <br />County /+ <br />,1 :F•, ON COM UTER/St4a <br />Ington Ave <br />Sanitary Permit Number (to be filled in by Co.) <br />S ,' Madison, WI 53707-7162 <br />-= <br />/ <br />it 0Q1I <br />Fssro�ti� <br />Sanitary Permit Application <br />State Transaction Number <br />-"3o979y6 <br />In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental unit <br />Note: Application forms for state-owned POWTS are submitted to <br />Project Address (if different than mailing address) <br />is required prior to obtaining a sanitary permit <br />the Department of Safety and Professional Services. Personal information you provide may be used for secondary <br />� s <br />purposes in accordance with the Privacy Law, S. 15.04(I)(m), Stats. <br />Parcel # 0�- Q �' 39/ -7-12 <br />I. Application Information - Please Print All Information <br />Property Owner's Name <br />,- (lam <br />Property Owner's ailing Address <br />Property Location /,,)G,/- <br />�j <br />Govt. Lot <br />S� y, s �/4, Section <br />City,State <br />Zip Code <br />Phone Number <br />[� G� <br />e�� % T r <br />. <br />T 7 C� N' R circlEone <br />,� <br />of <br />H. Type Building (check all that apply) <br />Lot # <br />Subdivision Name <br />P�ror 2 Family Dwelling - Number of Bedrooms - <br />Block # <br />❑ City Of <br />❑ Public/Commercial - Describe Use <br />�_.. <br />❑ State Owned - Describe Use r^ <br />El village of <br />l Town of Z__/-uC D <br />CSM Number <br />el <br />III. Type of Permit: (Check only one box on line A. Complete line B if applicable) <br />A. <br />❑ New System <br />9�2eplacement System <br />❑ Treatment/Holding Tank Replacement Only <br />❑ Other Modification to Existing System (explain) <br />I3. <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 appl <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 ent Area Information: <br />Design Flow (gpd) <br />Design Soil Application Rate(gpdsf) <br />Dispersal Area Required (st) <br />Dispersal Area Proposed (sf) <br />ZX-5 d <br />System Elevation <br />1679, -5 <br />VI. Tank Info <br />Capacity in <br />Total <br /># of <br />Manufacturer <br />Gallons <br />Gallons <br />Units <br />o° <br />� <br />New Tanks Existing Tankso <br />2 E i 72° <br />a U M m rn w 0 P <br />Septic or Holding Tank <br />41V v <br />Dosing Chamber <br />S� © --- <br />G e <br />— <br />VII. Responsibility Statement- 1, 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 />/ <br />227691 <br />715-349-7286 <br />Plumber's Address (Street, City, State, Zip Co—) <br />PO BOX 514, SIREN, WI 54872 <br />VIII. Coun /De artment Use Only <br />AApproved <br />❑ Disapproved <br />Permit Fee <br />1$375_,00 <br />�Date Issued Q� <br />Issuing Agent Si <br />El Owner Given Reason for Denial <br />IX. Conditions of Approval/Reasons for Disapproval <br />nD n <br />n <br />n APR 7 0 -7nig <br />Attach to complete plans for the system and submit to the County only on paper not less thamIj 1/2 1 inches in size <br />BURNETT COUNTY <br />ZONING <br />