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Co t <br /> i Safety and Buildings Division <br /> 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> en P.O.Box 7162 <br /> 1 Madison,WI 53707-7162 <br /> c •mil 63'"f <br /> Sanitary Permit Application State Transaction Number <br /> 11n accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit <br /> 1 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 -2 ? <br /> purposes in accordance with the PrivacyLaw,s.15.04 1 m,Stats. o` v ��A <br /> I. Application Information-Please Print A➢H Information <br /> Property Owner's Name Parcel# C)7 O A eaZ C v?O <br /> f a� <br /> / few/n; 9/�µ <br /> /S S� S` c� pOv <br /> Property 0 er's Mailing Address Property Location <br /> 3 4,- l Govt.Lot <br /> City,LState Q L Zip Code <br /> Phone Number q y, 14, Section .1260 <br /> It)/V J �//© 4'`� 336 �/6 (circle one <br /> T_�N; R_/Y E o <br /> II.Type of Building(check all that apply) Lot# 3 7/-3�2 <br /> 1 V,1 or2 Family Dwelling-Number ofBedrooms 3Ji 3V Ls/}/'.Subdivision Name ,f' <br /> Block# 7 L/� 74,J� /v• 0, <br /> ❑Public/Commercial-Describe Use ❑ City of <br /> } 0 State Owned-Describe Use ! CSM Number ❑ Village of <br /> PTOwn of <br /> i <br /> i <br /> III.Type of Permit: (Check only one box online A. Complete line B if applicable) <br /> A' ❑ Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> � i ❑i New System eplacement System g p y g Y <br /> B. i ❑ Permit Renewal El Permit Revision ❑ Change of Plumber ❑Permit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> ICI.Type of POWTS System/Component/Device: (Check all that apply) <br /> Anion-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dis ersal/Treatment Area Information: <br /> Desi gn Flow(gpd) Design Soil Application Rate(gpdsf) Di ersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> �171f.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units <br /> New Tanks Existing Tanks m <br /> i w U iq ti � w C7 0, <br /> Septic or IIOteling.Tawk gyp <br /> /p <br /> Dosing Chamber S-190 sw <br /> VII.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 RUFSHOLM f / � 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 <br /> VIII.Conn /➢9e artment Use Only <br /> Permit Fee Date Issued Issuing Agent Signature <br /> �pproved El Disapproved '­`j r <br /> ❑Owner Given Reason for Denial J �-.5-. ' Y-/-z, Zi iJ' <br /> I .Conditions of Approval/Reasons for(Disapprovaln D <br /> �/ L_ <br /> coiJ <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 iJhJ size 2021 <br /> 12 <br /> S;3D-6398(R03I3) <br /> Burnett County <br /> Land Services Department <br />