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-sa ' 41/v County <br /> Safety and Buildings Division ou r,02. <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 SA .-) ,...i . 0 <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 Projectdress If different than mailing address) <br /> the Department of Safety and Professional Servies. Personal information you provide may be used for secondary 2l /6��7 �' r <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. Z;.-7 `- , ^ C"'1 �/ <br /> I. Application Information—Please Print All Information . <br /> Property Owner's Name Parcel# 0 7 Q 3 6 A Ya / 7 il6 <br /> t <br /> ..%-r e/N$ O/ /A)3 L.L . oS ©a/ o/%oo lao <br /> Property Owne Mailt g Address Property Location AG/ <br /> 60 1 /' r / <br /> G/4!N`r/ e *ye 5 Govt.Lot <br /> Ci State Zip Code Phone Number y, /<, Section a 6 <br /> /S /)9, s <br /> V . yo fe 6/g 70/ 53a (circle one <br /> T ye) N; R /7 Eor <br /> II.MA <br /> of Building(check all that apply) Lot# <br /> ar 2 Family Dwelling—Number of Bedrooms .--- Subdivision Name <br /> �� Block# <br /> ....-- <br /> 0 Public/Commercial—Describe Use ❑City of <br /> ❑State Owned—Describe Use �— CSM Number ❑ Village of r <br /> --- JcI'own of 4W/Di✓ <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' ❑New System X.Replacement System ❑Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑ Change of Plumber ❑Permit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> i # Before Expiration Owner <br /> I IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> on-Pressurized In-Ground ❑ Pressurized In-Ground ❑At-Grade 0 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 /> 17'5— a , 7 6V3 iso 76. <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units ?. d <br /> New Tanks Existing Tanks v p Ti a g <br /> 0 <br /> U ii� �, w (.7 0. <br /> Septic or??ulding land <br /> / <br /> (I00 �_ /D(/t /) /l/r(Jo r W/es c--d ,z-- <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 ()0Je <br /> 227691 715-349-7286 <br /> 1 Plumber's Address(Street,City,State,Zip Code) <br /> i PO BOX 514,SIREN,WI 54872 <br /> VIII.County/{Department Use Only <br /> Approved I ❑DisapprovedP$ t �p Date Issued I 'n_A%,nt Signa e <br /> ❑ Owner Given Reason for Denial 6W re 11 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> r11ee,-- 4U Selioof C C� COMC� _l_ <br /> gas. <br /> JUN2U2022 <br /> Attach to complete plans for the system and submit to the County only on paper not less than t_//2 I in es i i siz e q <br /> Burnett County <br /> SBD-6398(R. 11/11) Land Services Department <br />