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County <br /> Safety and Buildings Division y /',,de, <br /> 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> Madison,WI 53707-7162 _ <br /> 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 a.cy,450 <br /> purposes in accordance with the Privacy Law,s.15.04(I)(m),Stats. <br /> 1. Application Information—Please Print All Information 416e)C) 4-1( m r <br /> Property Owner's Name r / Parcel# C).7 A 4 a 3 L(? ' a. <br /> (Th,il fciij ��j� 6)6 dot o.23e,ov <br /> Property ty Owner's Mailing Address Property Location,pG/ <br /> /v4/ e‘V e rgr e'e't) Ave Govt.Lot <br /> City,State ? Zip Code ' Phone Number <br /> IA <br /> „?S <br /> Al <br /> / / , /4, Section <br /> . c r o i 64/5 Liv 5143,24 / /l'-3 g'`J Y (circle ones.., <br /> IL Type of Building(check all that apply) Lot# T 3 N; R /cy E o tit J <br /> K' or 2 Family Dwelling—Number of Bedrooms . Subdivision Name <br /> Block#..------- <br /> ? ❑Public/Commercial—Describe Use <br /> ❑City of ,--- <br /> CSM Number ❑ Village of ----. <br /> ❑State Owned—Describe Use p <br /> e'.'"'' Town of L.l,el) { 6 i "e• f <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> r A' { ❑New System I J�.�,�s <br /> epiacement System ❑Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> ❑Change of Plumber List Previous Permit Number and Date issued <br /> B. ❑ Permit Renewal ❑Permit Revision g ❑Permit Transfer to New <br /> 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 ❑Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ( oiding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) 1 Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> VI.Tank Info j Capacity in Total #of Manufacturer I <br /> 1 Gallons Gallons Units 4 o Q <br /> New Tanks Existing Tanks v 2 ,, 6 a V) <br /> r U in tA cn w u P. <br /> Septic or Holding Tank <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 e) 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) �iL� <br /> PO BOX 514,SIREN,WI 54872 <br /> ' VIII.County/Department Use Only <br /> Permit Fee Date Issued Issuin A•g nt Signatur <br /> { Approved , ❑ Disapproved ssp�/ <br /> _ J ❑Owner Given Reason for Denial $3 7 �30/?a e,�T <br /> IX.Conditions of Approval/Reaso s for Disapproval 11„ �t1 <br /> i "6 5 <br /> 1D <br /> _AUG 19 2022 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 3 U i in size J <br /> Burnett County <br /> SBD-6398(R. I 1/11) Land Services Department <br />