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,. Ortp<' County, <br /> -` Safety and Buildings Division 41f"J <br /> S ton Ave <br /> 9 r;y Pet Number(to be filled in by Co.) <br /> 1400 E Washin <br /> S �"! P.O.Box 7162 Iv <br /> Madison,WI 53707-7162 <br /> �n x t4' � ✓��•� V� �/31f7 <br /> Sanitary permit Application State Transaction Number <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 J <br /> purposes in accordance with the PrivacyLaw,s.15.04 1 m,Stats. lJ' /"-7 <br /> I. Application Information-Please Print A➢1 Information <br /> Property Owner's Name 1 Parcel#07 p/ o?28 1-5-e y s" <br /> 6,J © � CAD 0.7t�000 <br /> Property Owner's Mailing Address ,� Property Location COL/ 9 3 f <br /> OS S/- Govt.Lot <br /> City,State Zip Code Phone Number y, Y<, Section <br /> i /' 4U/ 1� S—S- �sf �& cacle one <br /> II.Type of Building(check all that apply) � Lot# T _N, R E o> U <br /> � t <br /> or 2 Family Dwelling-Number of Bedrooms / Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of ^ <br /> ❑State Owned-Describe Use CSM Number ❑ Village of ,, � <br /> V-Town of L A d l/eh4e <br /> III.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 /> 13. ❑Permit Renewal ❑Permit Revision ❑ Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> Ton-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.Dispersal/Treat ent Area Information: <br /> Design Flow(gpd) I Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o'b <br /> New Tanks Existing Tanks i~ <br /> 0 <br /> a U A u c7 a <br /> Septic or NoWing.Tank <br /> Dosing Chamber <br /> VII.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 /> WADE RUFSHOLM /_/� / 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 <br /> VIII.Conn /Il)e artment Use Only <br /> 1 A Approved ❑Disapproved Permit Fee Date Issued Issuing Agent Signature <br /> $ s ,s q. z� <br /> ❑ Owner Given Reason for Denial 3 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> ��- <br /> � ECR [E <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x nc ins!➢�Y!! TT�" U^ <br /> 3 2r4l <br /> SBD-6398(R0313) <br /> Burnett County <br /> Land ServiM Department <br />