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County <br /> r` Safety and Buildings Division ,G'��n e <br /> = 201 W.Washington Ave., P.O. Box 7162Sanitary Permit Number(to be filled in by Co.) <br /> •,,. Madison,WI 53707-7162 2— <br /> �IaN � 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 addiess <br /> the <br /> purp <br /> oses a of Safety <br /> with the <br /> ssinal Se s.'i5.p4Personal information you provide may be used for secondary re 45-11,�y 5/ ve' cp <br /> p rP Privacy15.04(1)(m), <br /> I. Application Information—Please Print All Information <br /> Property Owner Name t Parcel# r-7 o/v2 aVt/S-/a 65 lS" <br /> VI—Ad�/m4,r eAK.5.t,' <br /> 7s-0 os6 coo <br /> Property Owne,•'e Mailing,Address ( Property Location <br /> f O t✓o C. i ,l re-eK c� OG bF Govt.Lot <br /> t City,State I Zip Code Phone Number f <br /> t / ,f /4, /<,, Section <br /> c h A„i l>A) /17,0 1 5 S3< 6 T 7�(3 N; R /$—circle oo°i <br /> IL. Type of Building(check all that apply) Lot# <br /> U�1 or 2 Family Dwelling—Number of Bedrooms y c' Subdivision Name o (� <br /> Block# �l Q �/r�•�Sr/f3 i A I y " <br /> 0 Public/Commercial—Describe Use <br /> ❑ City of <br /> } ❑State Owned—Describe Use r---- CSM Number ❑ Village of �- <br /> Town of s3 A C(<S,:'' <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> &ew System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑Change of Plumber List Previous Permit Number and Date Issued <br /> ❑Permit Transfer to New <br /> Before Expiration 1 i 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 /> ❑ 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 /> > -2 I I/3 6��0 7v, g <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units d <br /> IIH <br /> New Tanks Existing Tanks I ti <br /> ( i EU v'' , in w 3 p. <br /> Septic or ii.eitoiP 1'aftk `cl 0e) ` eV / ^of! it-Pe,s (-cJ <br /> Dosing Chamber L <br /> I <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> i Plumber's Name(Print) Plumber'slu �� Signature MP/MPRS Number Business Phone Number <br /> WADE RUFSHOLM 1 `./(/ (1 227691 715-349-7286 <br /> ' '^ � <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 <br /> VIII.County/Department Use Only <br /> Approved ❑ Disapproved Permit Feei <br /> ssued i ,Agt Signature <br /> �$ 5 6 l/^ ,� ���^'►^ <br /> t LiOwner Given Reason for Denial Q(/)� <br /> I .Conditions f Approv l/Reasons for Di pproval V <br /> a t f Se-E-bkcls $')''�l�:/ t - <br /> J 1 <br /> 20 16 v1 O <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2:11 incl es in size <br /> Burnett County <br /> Land Services Department <br /> SBD-6398(R. 11/11) <br />