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,i,' t, County <br /> Safety and Buildings Division Ay r,frti;e_tt— <br /> ,, <br /> I)S . 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> `� P 3 • Madison,WI 53707-7162 Jrs-N„z Z _!b 6(,I 31405 <br /> 1- <br /> . � � Chi <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 c. 5— ..V-G IA o <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. r <br /> I. Application Information—Please Print All Information f 'G��� , , <br /> Property Owner's Name 1 Parcel# n .7 CU/$ ,2 57 A .2 7 <br /> 6 fCt? 1t5rc-1+ ,J /5 d,?os c,/rant. <br /> Property Owner's/Mailing Address Property Location <br /> ( <br /> a y ys L 4llc.z., f/f.e_G✓ X,J Govt.Lot <br /> City,State Zip Code Phone Number y, /, Section <br /> Si r e� t,0 X _� / -7,,? 0,2 2 g 7 2 Z Z T 3? Ji (circle one <br /> N; Rie EoW) <br /> II.Type of Building(check all that apply) ....--- Lot# <br /> 'g 1 or 2 Family Dwelling—Number of Bedrooms 5 Subdivision Name <br /> Block# r"0 SSclii/ S I/iri L.5 <br /> i <br /> ❑Public/Commercial—Describe Use ❑ City of <br /> CSM Number ❑ Village of <br /> ❑State Owned—Describe Use <br /> ..... fieTown of i''I'7 'e t itJ'cL) <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' ❑New System Replacement System ❑ Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑Permit Revision ❑ Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <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 ❑ Mound>24 in.of suitable soil I 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 /> 7 5 0 /, 6, VS)7 yf7, 7/ 6 - Y. 7 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units 6 o b 2 <br /> i l5 Q U s. v, <br /> New Tanks Existing Tanks y c ?? Y -°'n 2 2 <br /> aEU c' �, 47: 3 A.. <br /> Septic or Ho nn t / 9 a 75 o e vCD of /, . t1`P .X., <br /> Dosing Chamber 7 C / <br /> "/ a�jr�.�t <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 /, <br /> !/��)`a_ 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 <br /> 1 Approved ❑ Disapproved Permit Fee d Date Issued Iss Age Signati <br /> / e <br /> ❑Owner Given Reason for Denial , /i <br /> IX.Conditions of Approval/Reasons for Disapproval / /, $/pi- <br /> fYl-e4 (1 5el-10 l <br /> i <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 r i 11 hes fat isiy..43 ZZ ?IL <br /> Burnett County <br /> SBD-6398(R. 11/11) <br /> Land Services Department <br />