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, RMI,,1. County <br /> Safety and Buildings Division /�elr/t) eLfit— <br /> i <br /> < D s _ 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> Madison,WI 53707-7162 SAN _9 Q_ 61-131-17.2. <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 3 V 7 *32$5 <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. / i <br /> I. Application Information-Please Print All Information CO/45/16(-fr i.) L/1 <br /> Property Owner's Name Parcel# 9 -7 ,C g 02 3 5' /'I /V <br /> -T t— e- illy L e. ( r/14 6— ea6— t9o 0/80a <br /> /80ao <br /> Property Owner's <br /> ner's Mailin Address Property Location <br /> v <br /> (70G+.1 e_r �G3 e� y <br /> Govt.Lot o2 <br /> City,State , Zip Code Phone Number /, <br /> l ��// q �/ /4, /4, Section <br /> 6 rad 4-/11 /n/1� J�.s� 5 ca/ /��' Se� '(circle one <br /> I RJ O N; R 7 E orj <br /> IL Type of Building(check all that apply) Lot# <br /> Vi(Lor 2 Family Dwelling-Number of Bedrooms 3 �� Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use 0 City of <br /> f ❑State Owned-Describe Use CSM Number ID Village of /"� <br /> I V y f) y( pTown of f t`=c:,)e rs/ <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> / <br /> A. XNew System y ❑ Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑Permit Revision List Previous Permit Number and Date Issued <br /> ❑ Change of Plumber ❑Permit Transfer to New <br /> I ( Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> ') ,.Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade 0 Mound>24 in.of suitable soil 0 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 /> 1/5 C : '7 d 4/3c) v <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units 0 o b 0 <br /> New Tanks Existing Tanks w c v <br /> cC v in „, c' u C7 a <br /> Septic or Saalfiing"Fank <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 RUFSHOLM227691 715-349-7286 <br /> IPlumber's Address(Street,City,State,Zip Code) <br /> I PO BOX 514,SIREN,WI 54872 <br /> VIII.County/Department Use Only <br /> 55 Approved ❑Disapproved $ it Fee OV Date Issued Issuin Age Sign•I'// <br /> ❑Owner Given Reason for Denial <br /> IIX.Conditions of Approval/Reasons for Disapproval % /"4 IX. co1�,7 <br /> ipt'a,r. �C;e\b ko `(1L X 50` from � <br /> w \\ �r > 25 CO� lr►% 'rank- � CEO V E � <br /> tli <br /> juAttach to complete plans for the system and submit to the County only on paper not less than 8 t/2 x 11 inin size~�� 2022 <br /> Burnett County <br /> SBD-6398(R. 11/11) Land Services Department <br />