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County <br /> Safety and Buildings Division Arlt)e.., <br /> S <br /> _ 201 W.Washington Ave., P.O. Box 7162 S,nitary Permit Number(to be filled in byCo.)`„ti Madison,WI 53707-7162 t�i -a 2—j 4 03 07 <br /> '(° ,.. i CTil`22 - l <br /> 44, <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 Servies. Personal information you provide may be used for secondary *12.02.a <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. AlI. Application Information-Please Print All Information ke., ga.o <br /> Property Owner's Name Parcel#v 7 ep/8 A 3,9 /6 ,26 y <br /> a.e.e.t) Proper-r/ 5 G.LC_ e2 o-o>d sr,,2z00e) <br /> IProperty Owner's Mailing Address Property Location <br /> /0 75- o j,2 3/y 5* Govt.Lot <br /> City,State l Zip Code Phone Number AJC �, Se- 1,, Section jj <br /> u 657-azo-/36C' (circle one <br /> c h e.+eJ( (� s7 717. T 7 ' N; R /6 E oe <br /> II.Type of Building(check all that apply) Lot 4 <br /> i1.or 2 Family Dwelling-Number of Bedrooms el / Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use ❑ City of <br /> - ...- CSM Number ❑ Village of <br /> ❑State Owned-Describe Use l <br /> V 19 P / 5----� ID"-Town of r'1'�'GN O rJ <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' iKNew System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> ) <br /> B. ❑ Permit Renewal ❑Permit Revision ❑ Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> W.Type of POWTS System/Component/Device: (Check all that apply) <br /> ANon-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/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> Co 70 , .7 Y51 700 94,7 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units -fl 5 o '° <br /> U ti <br /> New Tanks Existing Tanks o ? y - a cca <br /> /"' at U rn v, ti. C7 a. <br /> Septic ordittldT4'Sank /(2>O 05t) ` (iJ/f�5 ,mac <br /> Dosing Chamber / ✓V <br /> VII.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 i <br /> Approved ❑ Disapproved <br /> Permit ee DO Date IssuedeI��:Age%Sign.�.f f� <br /> ❑Owner Given Reason for Denial )"I /w + 1 <br /> IX.Conditions of Approval/Reasons for Disapprovale.., r 1.598 oT j <br /> . v.)eA Is-0 dei >50t -ccofn •,spec stA. ace. ,5 .�— <br /> 54Cm e.(cva-�ior rnk5k exac4. '16.Q 44 E © `= 0 V E <br /> d a-t D <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1 ,11 , hes In 5i ie 2 ` 2022 <br /> Burnett County <br /> SBD-6398(R. 11/11) land Services Department <br />