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County �/ <br /> u PA)and Buildings Division y C <br /> I '",i 1400 E Washington Ave Sanitary ermit Number(to be filled in by Co.) <br /> `, ,& IJ.! P.O.Box 7162 3/1�-Ai---4240 <br /> i r Madison,WI 53707-7162 <br /> Ctr'A1.-19 L 3/"L3 <br /> er <br /> Sanitary Permit Application State TransactionNumb <br /> 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 t different than mailing address) <br /> the Department of Safety and Professional Services. Personal information you provide may be used for secondary 1 503- 5 <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. � //�7 <br /> I. Application Information-Please Print All Information ///J- //140/t) G <br /> Property Owner's Name Parcel# cy 7 p AR aZ 47/6 /573 5 <br /> O/1i 16b41/`A) i6 o� 7D o�7cx5c41`153 <br /> Property Owner's Mailing Address / Property Location <br /> id o? //3/ If(/e. Govt.Lot <br /> Ckty,State Zip Code Phone Number p y,, /, Section /3 <br /> t <br /> b cis kti 5q02---3 S 7/S— 79-2 7S (circle one <br /> T 17i N; R �J E or / <br /> II.Type of Building(check all that apply) Lot# <br /> 'XL' or 2 Family Dwelling-Number of Bedrooms 4 /7 Subdivision Name I D <br /> 7d <br /> Block# At/"1 rndiO/t) QUA+' V ' <br /> ❑Public/Commercial-Describe Use . ' ❑ City of `- <br /> r <br /> CSM Number 0 Village of ) <br /> State Owned-Describe Use Town of V T jh <br /> �{L s d/V <br /> 1 <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. 0 New System / Replacement System0 Treatment/Holding Tank Replacement Only 0 Other Modification to ExistingSystem(explain) <br /> I <br /> B. I 0 Permit Renewal ❑Permit Revision 0 Change of Plumber 0 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 /> Non-Pressurized In-Ground 0 Pressurized In-Ground 0 At-Grade ❑ Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> I l OC) - 7 5,57 'ea 73 <br /> IVI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units � L �b .� <br /> New Tanks Existing Tanks . o ,a„ E i s <br /> 1 yJ� .O rn y Cl) t 0 0.i <br /> Septic or 5l Mi auk 570 0 /00 6 Lf� 42 i f-01�'LJ e 5 c e) ---/- <br /> Dosing Chamber <br /> VIII.Responsibility Statement- I,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.County/Department Use Only <br /> Approved 0 Disapproved Permit Fee Date Issued Issuing Ag nt Sige <br /> 0 Owner Given Reason for Denial $ . -7.r.------- 3 Z i/ ici. <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> eg 4P I5ed 3-,/ — <br /> I IECEENEfillAttach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 h size <br /> MAR 2 3 2021JSSD-6398(80313) <br /> Burnett County <br /> Land Services Department <br />