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! .`;yAR'r4iL';: County <br /> Safety and Buildings Division if,nA..) je-.,' <br /> T. 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> `�, ,- P.O. Box 7162 14N_�1-_rip <br /> Madison,WI 53707-7162 Jn `-' <br /> G3/" uG <br /> State Transaction Number <br /> Sanitary Permit Appflicati®n <br /> In accordance with SPS 383.21(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.15.04(1)(m),Stats. <br /> II. Application Information-Please Print All Information <br /> Property Owner'sName Parcel# c.'7 0 6 6" bZ 3,Y I 7 // <br /> C.A.(19( G-4 //i.y /e-r- 3 c v or) c,//e,0 v)�/D <br /> Property Owner's Mailing Address Property Location , / <br /> ,;.///' 7 9 5 et)e,,,..)s o„) ieci Govt.Lot <br /> City,State ZipCode Phone Number , 5 <br /> /�J / / 7- /<,> /<, Section / <br /> vV 1,5 fe r a .,z .5 7.F 3 3/7--9/7- / (circle one <br /> H.Type of I,wilding(checkall that apply) Lot# T• N; R / E o> <br /> p(` Subdivision Name <br /> 1 or 2 Family Dwelling-Number of Bedrooms --- <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> 0 City of <br /> ❑State Owned-Describe Use -- CSM Number 0 Village of //�� <br /> 1 O ATown of /L)t r?45 <br /> Iiilf.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' 0 New System Re lacement System y p y 0 Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> B. 0 Permit Renewal 0 Permit Revision 0 Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> liv.Type of POWTS System/Component/Device: (Check all that apply) <br /> lon-Pressurized In-Ground 0 Pressurized In-Ground 0 At-Grade 0 Mound>24 in.of suitable soil 0 Mound<24 in.of suitable soil <br /> ❑ Holding Tank 0 Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 300 7 4/ 9 ys'6) 73 7 <br /> VII.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o'd <br /> New Tanks Existing Tanks 2 o y A <br /> e, U iii % ri w 3 a, <br /> Septic or Holding Tank ;75-& 1..5-i) <br /> )�v / 4f./`;� 1\,�/ <br /> Dosing Chamber <br /> WE.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> WADE RUFSHOLM ��_J /'Di// _ 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) (/v <br /> PO BOX 514,SIREN,WI 54872 <br /> VIII.County/Department Use Only <br /> Approved 0 Disapproved Permit Fee Date Issued Issuing Agent Signature <br /> 0 Owner Given Reason for Denial $ ,/..7.5:...7.5:.D D 2 •Jed•74 hi./kl <br /> IX.Conditions of Approval/Reasons for Disapproval ni d I c5.- 1 <br /> ECEOVE <br /> Ill <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 i/ '11 dhes in�e\ ���� <br /> SBD-6398(R0313) Burnett County <br /> Land Services Department <br />