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_________ County <br /> .17 Safety and Buildings Division Ze <br /> ` - 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> . P Madison,WI 53707-7162 <br /> !---- State Transaction Number <br /> Sanitary Permit Application /` <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit �LC(v Cn <br /> 00 <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 9 730. <br /> purposes in accordance with the Privacy Law,s. 15.04(I)(m),Stats. /� <br /> I. Application Information-Please Print All Information • �V ertre4'!r) <br /> Property Owner's Name Parcel# <br /> -le FP 5,Pjii cf ie-1 <br /> Property Owner's Mailing Address Property Location Pam:/ <br /> / <br /> a2 b 3 4 4 74/ -re J Govt.Lot 676 <br /> City,State Zip Code Phone Number 7 <br /> /4, <br /> /4, Section <br /> mAipis 7)j.0- _3-* 7 G/2 -- n,2-/63Y ,•circle ones. <br /> II.Type of Building(check all that apply) Lot# T N. R �✓ E o G! <br /> Xi or 2 Family Dwelling-Number of Bedrooms 3 2 Subdivision Name <br /> Block# <br /> Public/Commercial-Describe Use — ❑City of r <br /> ❑State Owned-Describe Use CSM Number e� r❑Village of -� <br /> V13, i_cJ la-rown of LAce`/k tf e <br /> 1- <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. � <br /> New System !X Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> { <br /> B. ❑ Permit Renewal ❑Permit Revision .Change of Plumber ❑Permit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> 1 j Before Expiration i 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) I Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> y5`d 1 - .7 e Y3 6s /00.- <br /> VI.Tank Info Capacity in Total #of Manufacturer I <br /> Gallons Gallons Units o ,b, <br /> New Tanks Existing Tanks v c a) 1 p 2 cl <br /> k0 <br /> U n 15,. c7). wC7 a <br /> Septic or�mik /ede) __- /ko a I r / <br /> Dosing Chamber I 6eo �ejU 1 1 <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 227691 715-349-7286 <br /> 1 NexeZ.-- -- <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 <br /> �VIII.County/Department Use Only <br /> 1 Approved I ❑ Disapproved Permit Fee Date Issued Is in_' nt Sigma <br /> i ❑ Owner Given Reason for Denial t 0 (* <br /> IX.Conditions of Ap roval/Reasons for isapproval <br /> Meek A , ..y10, Cif =,1 <br /> SEE REVISION <br /> F .. J d 2022 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 to 1 n size <br /> I llp(0 Burnett County <br /> Land Services Department <br /> SBD-6398(R. 11/11) V75M) <br />