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County <br /> Safety and Buildings Division (I A)e, <br /> 1400 E Washington Ave <br /> g Sanitary Permit Number(to be filled in by Co.) <br /> 4 ; : P.O.Box 7162 6 A W -0I 203 <br /> Madison,WI 53707-7162 <br /> 374 <br /> Sanitary Permit Application State Transaction Number <br /> Iin 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 /> ;lie Department of Safety and Professional Services. Personal information you provide may be used for secondary ;2 O+t-�7 <br /> ' _ <br /> urposes in accordance with the Privacy Law,s.15.04 i)m,Stats. v� O J <br /> L Application Information—]Please Print All Information /¢- /77 'n"d 7--r <br /> I Property Owner's(Name Parcel# 7 <br /> o10A) <br /> j Property Owner's Mailing <br /> dress Property Location �-7�,f <br /> 3 2 /l AJ err � A Govt.Lot <br /> ity,State Zip Code Phone Number /4 <br /> /� _ /4, Section�� <br /> Nee r/STD}- lV� 5 5376 `75r2 NS-`� S a T�/�N; R � (circle EcDew <br /> JU.Type of Building(check all that apply) Lot# <br /> Subdivision Name <br /> or 2 Family Dwelling—Number of Bedrooms <br /> Block# /¢'# geld Y <br /> 1 ❑Public/Commercial—Describe Use ❑City of <br /> State Owned—Describe Use CSM Number El Village of <br /> i P/qbwn of '04 G S <br /> I � <br /> HE.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' 1 ❑New System $Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain.) <br /> f <br /> j 1 List Previous Permit Number and Date Issued B. i ❑ Permit Renewal ❑Permit Revision ❑ Change of Plumber ❑Permit Transfer to New <br /> Before Expiration Owner <br /> i Zvi.T e off )WTS teen/Com onentl Device: (Check all that apply) <br /> on-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> Hoiding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> CJ.Dispersal/Treat nt Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> go <br /> 7 �yl.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units ,p o 0 <br /> 1 New Tanks Existing Tanks o , P- y <br /> a U nn i£C7 a. <br /> Septic or�r , nk D (� QQv /(�Cl' ji✓ei S G <br /> Dosing Chamber <br /> i <br /> 1 `/IIII.Responsibility Statement- d,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> I Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> I ADI E RUFSHOLM / 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) Ml�� <br /> PO BOX 514,SIREN,WI 54872 <br /> I <br /> VIII.Coun /1®e artment Use Only <br /> I }J{)Approved ❑Disapproved Permit Fee <br /> Date Issued A nt Sign e <br /> ( \ ❑Owner Given Reason for Denial •/ -7' 0 . 7/ <br /> RX.Conditions of ApprovalMeasons for]Disapproval f � <br /> nPC � CE0YE <br /> I ni <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1R x in u to s�¢t N 2 5 2021 <br /> SBD-6-398(R0313) � B <br /> Burnett County <br /> Land Services Department <br />