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i., County .t.7.- <br /> Safety and Buildings Division /.-�c1!/ ,/Ill e <br /> _ 201 W.Washington Ave., P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> ' Madison,WI 53707-7162 5/41\)_ _,J d 62//3,/t� <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 <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. <br /> I. Application Information-Please Print All Information ' <br /> Property Owner's Name ! / Parcel# <br /> I- MLk5 ��sl/i.5 <br /> Property Owner's Mailing Address i Property Location <br /> r9- Ca 74/ eVbriii Re Govt.Lot <br /> City,State Zip Code Phone Number <br /> /<, /, Section 9_ <br /> G.,,,A., 1 $6,,,, ,J. -5 z/eFY0 7/5f- 77/-7/4;2 q (circle one <br /> T �J N; R /a- Eoe9 <br /> II.Type of Building(check all that apply) Lot# <br /> f i or 2 Family Dwelling-Number of Bedrooms 3 <br /> / Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use ❑ City of <br /> {I <br /> ❑State Owned-Describe Use 1 C1S/M Number ❑ Village of <br /> V e i /D 4 Town of e tJ, "4-(j47i+3 <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' ❑New System <br /> y 1 Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision <br /> ❑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 /> ❑Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑At-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> i-lolding 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 /> 3P® <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units u, o b <br /> New Tanks Existing Tanks w = y = 8 m 2 <br /> 0 <br /> I U n w C7 G. <br /> Septie or Holding Tank [) 1 *- <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 (�G// e /' • 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 <br /> /III.County/Department Use Only <br /> Permit Fee Date Issued Is 'n Ag t Sign e <br /> il Approved ❑ Disapproved <br /> ❑Owner Given Reason for Denial $.375 1151?VI <br /> IX. onditions of Approval/Reas ns for Disapproval I )5 3 71'-t7- <br /> �'1e� a 6t Se-I-�. 3� Needs qc6.- t(o(�i r ECEOv m <br /> CXT e i5 �e '� :' ,c,nk a I�eine,n4. D <br /> V �, <br /> 1 L n <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2: i ins e� �`'�� I <br /> Burnett County '—J <br /> SBD-6398(R. 11/11) Land Services Department <br />