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„,c,. t0-.0 County /‘ <br /> Safety and Buildings Division /� et a^K t`,f <br /> 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> `• •� r 6 Madison,WI 53707-7162 643 y is <br /> 045-1--,Q,2 17 <br /> 1--- State Transaction Number <br /> Sanitary Permit Application <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 /02 S ,9'a •, zqs?d <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. I <br /> I. Application Information-Please Print All Information �9�'�^ ief erj'e ..� <br /> Property Owner's Name Parcel# p 7 0 9 a,2 aZ 3 S' /V / 7 <br /> ,61;4c*-- 40 t-/ i LL c /s 0,5--6 e//oe, <br /> Property Owner's Mailing Address Property Location <br /> 3 U G R 0) 51: AJ& Govt.Lot <br /> City,State Zip Code Phone Number y, /, Section / 7 <br /> (circle one) <br /> A-IUc)6 VE'-(� In A. .516---,3 e> 4/ 7GJ�'yy�'4'� 3 T ....7O N; R /5-1 EorW <br /> IL Type of Building(check all that apply) Lot# <br /> or 2 Family Dwelling-Number of Bedrooms / Subdivision Name <br /> '' {` Q F <br /> Block# IN cf>Od /�i di <br /> El Public/Commercial-Describe Use , / <br /> ❑City of <br /> ..--- -' CSM Number ❑ Village of <br /> El State Owned-Describe Use / <br /> .----_ Town of id e'c/ /A°/ 0 f'..r” <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. i �New System ❑Replacement System ❑Treatment/Holding Tank Replacement Only El Other Modification to Existing System(explain) <br /> ) <br /> B. ❑ Permit Renewal ElPermit 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 /> ( Ion-Pressurized In-Ground El Pressurized In-Ground ❑At-Grade El Mound>24 in.of suitable soil El Mound<24 in.of suitable soil <br /> El Holding Tank El Other Dispersal Component(explain) El 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 /> y5-0 ; .� 770 70 0 ?5, SVI.Tank Info Capacity in Total #of Manufacturer 0 <br /> Gallons Gallons Units ti o <br /> New Tanks Existing Tanks y o ;? E u . IA <br /> U In v, rn 4. 3 p. <br /> Septic or HeitiineiVik iL,O0 — /IJ06 / moi (-Li L-5 <-L-j <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) Plumber's Signature MP/MPRS Number Business Phone Number <br /> WADE RUFSHOLM 1..N ,i 227691 715-349-7286 <br /> til a s / - <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 <br /> VIII.County/Department Use Only <br /> Permit Fee Date Issued I t g Age tgnatu <br /> Approved ❑ Disapproved $ / // il <br /> ❑ Owner Given Reason for Denial Li 25 D i 12? gn <br /> IL Conditions of Approval/Reaso for Disapproval r'�:/''� .62/ <br /> v��a ko Ix "so' ro m dtt'aa n ��6I ?ZS' -cro m a an k.• E C L5 O V E 1 <br /> /nee'- Ql I s4 c 4 <br /> ■ 1U �� <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 t/ ill hes in'size' ��� <br /> J <br /> Burnett County <br /> SBD-6398(R. 11/11) Land Services <br />