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County <br /> _ Safety and Buildings Division At C <br /> i 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> P.O.Box7162 <br /> Madison,WI 53707-7162 3.7 G 'FX <br /> / <br /> State Transaction Numlier <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 /> 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 --z — C�'7 - <br /> i)umoses in accordance with the Privacy Law,s.15.04(1)m,Stats. <br /> i II. Application Information—Please]Print All IInfornlationt Sohn-'E;l j- <br /> Property Owner's Name Parcel# Q 7 C}1,2 a C/© 1 a3 <br /> Property Owner's Mailing Address Property Location OC_ <br /> ��5/d D �7►� / T�j/ / RC� Govt.Lot <br /> i city,Stare Mp Code Phone Number y< ' J <br /> /., Section aj <br /> (circle one) <br /> T !/,0 N; R Eorr7-11 <br /> III.Type of Budding(c➢aeck all that apply) Lot# <br /> I or 2 gamily Dwelling-Number of Bedrooms Y 3 Subdivision Name <br /> Block# <br /> .,3oti^/a,ommercial-Describe Use El city of <br /> -� CSM Number ❑Village of <br /> j u State Owned-Describe Use <br /> / [�1'`�� ownoff�t�fZ <br /> i <br /> .I.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> New System Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> I <br /> - ; ❑ Permit Renewal ❑Permit Revision ❑ Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> i <br /> i W.Type of IPOW II S System/Component/Device.- (Check all that apply) <br /> Non-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) (explain)_ <br /> ❑Pretreatment Device <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 /> boa 1 17 1 95-:6 -5-" / <br /> VII.Tanis Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units _, ? <br /> New Tanks Existing Tanks o 2 i a <br /> 111; U m A <br /> Septic or I4QidiagL:aU c 2 C- <br /> I Dosing Chamber <br /> VU.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 /> i 'JADE RUFSHOLM , / ,p�/� 2276, 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 <br /> { <br /> i VIII.Conn /IDe artment Use Only <br /> Permit Fee Date Issued Issuing Agent Signature <br /> Approved El Disapproved $ � <br /> ❑ Owner Given Reason for Denial .37Jr. � 2/•21 <br /> UK.Conditions of Approval/Reasons for(Disapproval CIK 7 �V.;S— <br /> H <br /> i <br /> i <br /> Attach to complete plans for the system and submit to the County only on paper not lees than 8 1!2 x 11 size � �t'GV!` <br /> SBA-c4398(R0313) <br /> Burnett County <br /> Land Services Department <br />