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tiir:;;. Count <br /> "<; Safety and Buildings Division ,j yr.A)ell- <br /> , 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> . ST ' IR' P.O.Box7162 :2.1 -136 <br /> Madison,WI 53707-7162 <br /> r,, ' .3.-. 1L7 <br /> Sanitary Permit Application State TransactionNumber <br /> ,-/ <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(jf,diffeyent than mailing address) <br /> the Department of Safety and Professional Services. Personal information you provide may be used for secondary /66,6 <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. „1/ /1�{ Li: 0 <br /> I. Application Information—Please Print All Information ,V /� J ///����/// <br /> Property O ner's Name <br /> ,S' Parcel# o 7 o3 y 237/2 /7 <br /> p Y <br /> e 1/�. Te it f©/t) , 05r Obi 0//..;200 <br /> Property Owner's Mailing Address Q Property Location PG/ 35%7-3 <br /> at 2v- 6 / �,�i i3 /C� Govt.Lot <br /> City,State / J j Zip Code Phone Number yq V., Section /7 <br /> G r/4��5-6 4i` GJ.. y#, dao-d 9S_, <br /> code one <br /> T .37 N; R /0 Eoit <br /> U.Type off Building(Elteck all that apply) Lot# <br /> 1.-or 2 Family Dwelling—Number of Bedrooms (72- / Subdivision Name <br /> Block# <br /> ❑Public/Commercial—Describe Use 0 City of <br /> �--- CSM Number 0 Village of <br /> ( ❑State Owned—Describe Use / <br /> 1/O� 7 p 7S--- Mown of 7). /fe L 4 t <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> jac- ew System 0 Replacement System 0 Treatment/Holding Tank Replacement Only ❑Other Modification to ExistingSystem(explain) <br /> B. 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 0 Mound>24 in.of suitable soil 0 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(sf) System Elevation <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units 2 U,b, 0 <br /> New Tanks Existing Tanks ,w", o y L I <br /> a. O in a cn w C7 0, <br /> epiiaor Holding Tank f <br /> .S <br /> �?l3�(� F-- „C / /�-5 ctr` yL <br /> Dosing Chamber <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plubmis Signator MP/MPRS Number Business Phone Number <br /> WADE RUFSHOLM /, _ / 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) '�e� <br /> PO BOX 514,SIREN,WI 54872 <br /> VIII.County/Department Use Only <br /> Permit Fee Date Issued Issuing gent„$rgnature <br /> Approved 0 Disapproved �'ly _ <br /> i� f <br /> ❑Owner Given Reason for Denial $3 -5 ‘5..."2.J" Z/ <br /> IX.Conditions of Approval/Reasons for Disapproval 42 © EllVEll <br /> MAY 14 2021 <br /> I <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 l/1 x II inifhes insize i <br /> Burnett County <br /> SBD-6398(80313) Land Services Department <br />