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,r. ,r' County)2 <br /> ---?-.,:sSafety and Buildings Division 4f c.2% <br /> 'i 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> �. 1T. P.O. Box 7162 Glv "Al -I 7 <br /> l Madison,WI 53707-7162 <br /> .:xe..,.,c•r:nti: P -a2L--Lk, <br /> Sanitar Permit A��licatio State Transaction Number In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit X3(454/ <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 975 j j� g b t,/�1/ <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. /� <br /> E. Application Information-]Please Print Ali Information rSL <br /> Property Owner's Name Parrrl if <br /> 07-016-2-39-17-23-2 02-000-011200 <br /> Property Owner's Mailing Address Property Location/3 <br /> 7,g (/ Z6 Govt.Lot 3 0—(-6 <br /> City,State Zip Code Phone Number /i l...) 1/4N44.f y,, Section <br /> L i_ivj 55 6 /-3.53, 3,...57 (circle on <br /> G .S /�C'./Vl /'n/U c 4' _ T 3Y N; R/7 E <br /> ri.Type of Building(check all that apply) Lot# <br /> ❑ I or 2 Family Dwelling-Number of Bedrooms 5 , . Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use - <br /> — <br /> ❑ City of <br /> ❑State Owned-Describe Use <br /> / 5/1 ` f/ <br /> �_ CSM Number [❑y Village of <br /> x24/ Town of G//JC_t,/i't) <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. $ lew System 0 Replacement System yp y ❑ Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> 7-Non-Pressurized In-Ground 0 Pressurized In-Ground ❑ At-Grade ❑ 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(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> V..50 / 7 6 4/3 6- 2 95s 5— <br /> VII.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units fl I'3, e12 t b, u <br /> New Tanks Existing Tanks ° y , m <br /> a U FA y m w C7 P, <br /> Septic or Noldiug-Tenk /40‘? /Pa) / /r/o rcc)cis C--c, <br /> Dosing Chamber <br /> VII.Responsibility Statement- 1,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 RUFSIIOLM i)4' �J 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) yJ�C <br /> PO BOX 514,SIREN,WI 54872 <br /> VIIIII.County/Department Use Only <br /> pckApproved ❑ Disapproved Permit Fee Date Issued Issuing Agent Siggaturc <br /> 0 Owner Given Reason for Denial $ 37'r.f 3 y/. ����/////1\/ <br /> TX.Conditions of Approval/Reasons for Disapproval J J nc <br /> C © E OVE m <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 1 i I es VAR <br /> 1 5 YL 4 <br /> 1'l (U _I <br /> SBD-6398(R0313) <br /> Burnett County <br /> Land Services Department <br />