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r,n, County <br /> Safety and Buildings Division ,e c1/ 1 4; <br /> `-' 1400 E Washington Ave <br /> g Sanitary Permit Number(to be filled in by Co.) <br /> � '' 1N'I P.O.Box 7162 <br /> .. 5'Pl-q—. — c <br /> .. `�._-.- 7.' J: Madison,WI 53707-7162 G3-5-/44 <br /> State Transaction Number <br /> Sanitary Permit Application <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 al 0 5-c-) <br /> Cj a <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. 0 <br /> II. Application Information-Please Print MI Information -,1171',1/414) Rd <br /> Property Owner's Name Parcel# 0 7 7 p4Z& a 4/6 /4., /g 3 <br /> Ke-4) fiaier e7 --2 e,r)n c3/ROO 0 <br /> Property Owner's Mailing Address Property Location /p e_/ ',3399 <br /> 76 C y 3/-sus f ,J Govt.Lot City,State - Zip Code Phone Number /1) W S L&) 1/4l g <br /> Section <br /> c/t'kCi4'Ie ,i1 5-57a7 a?Si 651 //`/(circle one <br /> T �� N; R /O E or l <br /> III. !:type of 1Brtilding(check all that apply) Lot# <br /> Xi.or 2 Family Dwelling-Number of Bedrooms t2 / Subdivision Name <br /> Block# _ <br /> ❑Public/Commercial-Describe Use 4-- ❑ City of <br /> 0 State Owned-Describe Use CSM Number 0 Village of �y' <br /> V ?Town of '4 I 'I A•/�•C <br /> p %/ <br /> DIE.Type of Permit: (Check only one boa on line A. Complete line B if applicable) <br /> A. 1 ❑New System Replacement System ❑Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal 1 0 Permit Revision 0 Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> I <br /> I Before Expiration I Owner <br /> PT.Type of POWTS System/Component/Device: (Check all that apply) <br /> ,.Ton-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade 0 Mound>24 in.of suitable soil 0 Mound<24 in.of suitable soil <br /> ij Holding ❑Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) I Design Soil Application Rate(gpdsf) Dispersal Area Required(se Dispersal Area Proposed(se System Elevation <br /> ��C) I - `7 /- V 41s?-7 9.:.5 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units E. b y <br /> New Tanks Existing Tanks <br /> o e y ..oce <br /> n• U cn ti co w(7 Ti.,c, ' <br /> Septic or f leidittg Truk `j y .0)75/° !e <,i e/. <br /> dosing Chamber S-O'' =� 5-aa <br /> I .Responsibility Statement- .l,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 /'1 je 227691 715-349-7286 <br /> { Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 <br /> V][III.County/Department Use Only <br /> Permit Fee Date Issued Issuing Agent Signatyufr. f 11 ' <br /> Pypproved ❑Disapproved r / i'�/i��'c•6r''wlY <br /> 0 Owner Given Reason for Denial $ .�7J• / 4 •7.2•/ (*1 p <br /> 1121.Conditions of Approval/Reasons for Disapproval D v <br /> IED <br /> JUN - 7 2021 <br /> Attach to complete plans for the system and submit to the County only on paper not less han 81/r x 11 inchesin sine A <br /> Burnett County <br /> SBD-6398(R0313) Land Services Department <br /> t`t+- is ? *--06a <br />