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,---- Coun <br /> Safety and Buildings Division 4 y c^/1) c:_ <br /> /-/- <br /> _ 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> il, Madison,WI 53707-7162 S�.22_ .2� <br /> A G-r-.2Q - 151 G�-f� � <br /> Sanitary <br /> ita Permit <br /> Application <br /> lflcation 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 1f different than mailing address) <br /> the Department of Safety and Professional Servies. Personal information you provide may be used for secondary /2C)3 <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats.I. Application Information-Please Print All Information GA41^i eV5o� Lk <br /> Property Owner's Name t c Parcel# p J p 3v 02 37/ ,, S' 3 <br /> - IrA'cI Q Xider 01;h *ers C)y aoa o/fe©v <br /> Property Owner's Mailing Address Property Location <br /> / c P q j!'c ,4 19� Govt.Lot <br /> City,State / Y ; Zip Code Phone Number 1, SL J y,, Section �� <br /> t I e ri c �✓�t/ Ij 5 Vg� .Sc7 circle one <br /> ' T 7 N; R /i0 E tit <br /> H.Type of iruilding(check all that apply) Lot# <br /> igt or 2 Family Dwelling-Number of Bedrooms — Subdivision Namme <br /> } �_ Block# <br /> U Public/Commercial-Describe Use <br /> .-- ❑City of <br /> -,---- CSM Number ❑ Village of <br /> ❑State Owned-Describe Use J r /y <br /> .i— X Town of Tr/ e- A- <br /> E <br /> III..Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> r <br /> A' ❑New System 'replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> = j r List Previous Permit Number and Date issued <br /> B. 0 Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑Permit Transfer to New <br /> Before Expiration I Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> KNon-Pressurized In-Ground El Pressurized In-Ground El At-Grade ❑ Mound>24 in.of suitable soil Cl Mound<24 in.of suitable soil <br /> 3 <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) Cl 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 /> 300 i 4 g ; 373 379 77 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units 2 o - <br /> New Tanks Existing Tanks W y y , a ca m <br /> I i e U n y cn w 3 a., <br /> Septic or il< O` 700 , 7 f I<,4ti,1 <br /> �J -7 Dosing Chamber '7 z, /a 0 / (.4).r`�' ,- I <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 Sign re MP/MPRS Number Business Phone Number <br /> WADE RUFSHOLM i�/� �_ 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) / ���lll������ <br /> PO BOX 514,SIREN,WI 54872 <br /> VIII.County/Department Use Only <br /> i Permit Fee 0 Date Issued uing ent Sign <br /> a roved ❑ Disapproved f� Os <br /> pp $ '1�5 C/ ?� �Q • <br /> ❑Owner Given Reason for Denial <br /> { IX.Conditions of Approval/Reason for Disapproval CK I{p(ai `b qg6 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 inches1[ECEOWIE7- <br /> AUG 2 3 2022 <br /> Burnett County <br /> SBD-6398(R. 11/11) Land Services Department <br />