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1 Safety and Buildings Division ga'jam <br /> 1 201 'IV Washington Ave., P.O.Box 7162 Sanitary Permit Number(to be fitter b7 Co.) <br /> A� S." elit Madison,WI 53707-7162 _a `C gg' I , <br /> State Transaction Number <br /> Sanitary Perniit Application <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 2 g/.4 <br /> purposes in accordance with the Privacy Law,s. 15.04(i)(m),Stats. `7 � <br /> 1, Application Information-Please Print All Information • _ V4)�S A 13 /1 <br /> Prkperty Owner's Name Parcel# o-7 pig. •a 3 7 /6 3y-SI <br /> ,e_ 0 rA I) J o rz rs7e-r /G S9 S o /Shoo <br /> Property Owner's Mailing Address Property Location <br /> 6 yo ieUr9 qd y {J i r. GovtLot <br /> City,State ! Zip Code Phone Number , ,/ <br /> EA i Jt ) /0 4).e ;5 s/ 2 z 66-/`0276`386/ /(circle one) <br /> H.!, of Building(check all that apply) Lot# T .3� N; R`E� or'• <br /> f y Subdivision Name <br /> ':. or 2 Family Dwelling-Number of Bedrooms P. `3 t9ti/ / <br /> _ Block# A N�2J�o.S�}' kescOI j Ci f 0 <br /> Li Pub'dic!Con-,rneroiai-Describe Use ,..____- <br /> ❑City of <br /> 0S CSM Number 0 Village of <br /> State^wneo-Describe Use <br /> %Town of /22 veto.0 O' . <br /> :III.Type of Permit: (Check only one boa on line A. Complete line B if applicable) <br /> A. LA a New System I Replacement System I ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> i <br /> , <br /> Permit Previous Permit Number and Date issued <br /> rs <br /> ! PermitRenewal I ❑ a ermit Revision I ❑Change of Plumber ❑Permit Transfer to New <br /> Before Expiration E j Owner <br /> . i c <br /> 1_'II Tyre of,POSTS System/Comporaent/IIDevice: (Check all that apply) <br /> ' 0 Non-Pressurized0 Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> i in-Ground 0 Pressurized In Ground 0 At-Grade <br /> oiding Tank 0 Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> i V.Dispersal/t s eatment Area Information: _ <br /> Design Flow(gpd) ii Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> 02Oa <br /> IV➢.Tank nfo I Capacity in Total #of Manufacturer <br /> I Gallons Gallons Units 0 o „ <br /> 1 New Tanks I Existing Tanks w a 0 a' 6 w <br /> a> c «. m, a; .o <br /> i Ct 0 Cn v) j al t7 ci, <br /> sieekie or cici;rg Tank i jd�6 I �OOD /re !'-- <br /> I <br /> Dosing Chamber i M , <br /> V$..Responsibility y Statement- Z,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> • Plumber's Name(Print) I Plumber's Signature MP/MPRS Number Business Phone Number <br /> WADE RUFSHOLM f �/ , 227691 715-349-7286 <br /> (!�/ <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PG BOX`i ,SIREN,WI 54872 <br /> VIM .County/Department Use Only <br /> kppr vec 0 Disapproves Permit Fee Date Issued Is i ent Si <br /> :. 0375� 8/l6/2; <br /> { u Owner Given Reason for Denial <br /> IX.Conditions of 7Proval/Reasons f r Disapproval <br /> 5e -c it k Q,�.rs n,u be 6 of a.be�- 558. <br /> e TECEOWETh <br /> Attach to complete;Mans for t tie system anal submit to the County only on paper not less than 812 xs*fib j L 2022 <br /> rn�vv' i I <br /> SBD-5398(P� Burnett County <br /> I nn 4 Caroinae flonartmont <br />