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Safety and Buildings Division p� <br /> 1400 E Washington Ave Sanitary permit Number be filled in by Co.) <br /> Ir4, P.O.Box 7162 <br /> Madison,WI 53707-7162 ~, <br /> State Transaction Number <br /> Sanitary Permit Application <br /> i in accordance with SPS 383.21(2),Wis,Adm.Code,submission of this form to the appropriate governmental unit <br /> i is required prior to obtaining a sanitary permit. Note:Application forms for state-owned POWTS are submitted to Project Address(if different than ma:mg address) <br /> tine Department of Safety and Professional Services. Personal information you provide may be used for secondary ` t <br /> J oses in accordance wiflt the PrivacyLaw,s.15.04(1)(m),Scats. /D 6 /i //'Y ` �►[� <br /> 1 li. Application Information—]Please(Print All Information <br /> ?ro erty Owner's Name Parcel# Q O <br /> o <br /> i ?rope, Owner's Mailing Address Property Location V(:Z. <br /> ::e �•Z D <br /> 1 D a Govt.Lot <br /> i riiy,Stale Zip Code Phone Number A�y, _ y, Section <br /> Pe Kl T �N' R circiEoonel/ <br /> i 5R.Type of 150ding(check all that apply) Lot# <br /> or 2 Family Dwelling—Number of Bedrooms Subdivision Name <br /> Block# <br /> PzYNic/Coinmercial—Describe Use <br /> El City of <br /> CSM Number El Village of <br /> FJ State Owned—Describe Use <br /> Townof T L-/ffke <br /> i <br /> i <br /> Ea.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. } <br /> New System ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> a <br /> I <br /> i <br /> !M• ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑Permit Transfer to New List previous Permit Number and Date Issued <br /> Y i <br /> Before Expiration Owner <br /> W.T S e of POWTS 3,stem/Oom onent/IIDevice: Check all that apply) <br /> j ❑ Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> i — <br /> { K-1-loiding Tanlc ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dis ersaD/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> �\q.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units 1, ? U N <br /> New Tanks Existing Tanks <br /> iS FQWoT Holding Tank <br /> i Dosing Chamber <br /> t <br /> `Tjll.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> r Plumber's Name(Print) Plumber's Si ature MP/NIPRS Number Business Phone Number <br /> j 'WADE RUFSI-IOLM /_� 227691 715-349-7286 <br /> I Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 <br /> { <br /> i `JM.Conn /➢De artment Use Only <br /> Permit Fee Date Issued Issu//ing Agent Signatur <br /> Approved El Disapproved <br /> e <br /> t © Owner Given Reason for Denial `— <br /> T"N.Conditions of Approval/Reasons for Disapproval <br /> C 11 , <br /> CC� L U M CE <br /> /M <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 i inJ size <br /> U N 17 �� <br /> 211 IU <br /> S31�-c4398(12fl3 i3) <br /> �� ? r..9 -e Burnett County <br /> Land Services Department <br />