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``, ktr,.i County <br /> ` Safety and Buildings Division /5 .-, T ti L. <br /> ® y 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.)) <br /> `',. P; Madison,WI 53707-7162 1R-IJ _a2 -�7 643414 <br /> ,,ic. <br /> ; � <br /> . ' C'_r`V-a_ , -,2-3 <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 j / 7. f 4 1$57 5 <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. /?P/ <br /> I. Application Information—Please Print All Information L o / <br /> i % /t . <br /> Property Owner's Name i Parcel# o-, ,7 2 ,1 47/4 /y S <br /> A> <br /> /�}'I/ 1 5CM) nn <br /> .-r r i c k s o - 0,,,/ a /i0 <br /> Property <br /> Owner's Mailing Address a n Property Location <br /> S ! 5 Y ft'tic! CO C?t /- /�c �" ��} Govt.Lot _ <br /> City,State Zip Code Phone Number _ y4 /a, Section <br /> LAC re 55 W'-g- 5—yZ° / 605--Zj 2 7375 circle one <br /> T y() N; R /� EoJW, <br /> II.Type of Building(check all that apply) Lot# <br /> X-I-or 2 Family Dwelling—Number of Bedrooms .2 Subdivision Name <br /> Block# <br /> ❑Public/Commercial—Describe Use ❑City of -- <br /> CSM Number ❑ Village of <br /> ❑State Owned—Describe Use <br /> v/7 3 a Town of SC <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' 0 New System Replacement System 0 Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> B. 0 Permit Renewal 0 Permit Revision 0 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 /> Mon-Pressurized In-Ground 0 Pressurized In-Ground 0 At-Grade ❑ Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> 0 Holding Tank 0 Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) I Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 7 3--0 i !- 6 47/6 '7 G E 7 9 5 <br /> VI.'Tank Info Capacity in Total #of Manufacturer a) <br /> Gallons •Gallons Units f, 6 U c y <br /> New Tanks Existing Tanks y g a; Y ,8 . cl <br /> 1 Septic or Holding Tank / o% /re>o --2(ice) ��, ,c... ,'•z e.S c c-, <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 ``// Z. 73--- 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 /> Approved 0 Disapproved PPermit Fee Date Issued Iss ' Agen lgnatu ,,' / <br /> ❑ Owner Given Reason for Denial • / �� <br /> , <br /> IX.Conditi s of A prova oaso for Disapproval - ��� <br /> ate A,G 5c EC G NI C <br /> MAR 2 3 2022 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 1 i es in size <br /> Burnett County <br /> SBD-6398(R. 11/11) Land Services De•artment <br />