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,,,aH rig-,, County, y� <br /> Safety and Buildings Division ,(3 tl/�o.1 C7- <br /> '> ; p 1 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> SP S �`! Madison,WI 53707-7162 <br /> Gf,nv t :23 - t70 lQS 04y <br /> —.a <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 <br /> is required prior to obtaining a sanitary permit. Note:Application forms for state-owned POWTS are submitted to ProjectAddress(if different than mailing address) <br /> the Department of Safety and Professional Servies. Personal information you provide may be used for secondary a/ 96 ? <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. �1: Y- �R /1c e5 5 <br /> I. Application Information-Please Print All Information 1� <br /> Property Owner's Name Parcel# D 7 03y 42 3 7 jr 42 S <br /> C0Mp/'e* "rep 42-r77 es LLC. 05- op/ oa 5CO.f, <br /> Property Owner's Mailing Address /' Property Location , c. <br /> .0 9'7 //1}q g7 —t' 40 Govt.Lot <br /> City,State •/ ' Zip Code C/ Phone Number y q y,, '/<, Section . /2. <br /> /T�/h/It2 fG� �t ,-5-0-7/ kg-25a-8.6 / / T .5 7 N, R�$(circlE oori <br /> II.Type of;wilding(check all that apply) Lot# r� <br /> -I-or 2 Family Dwelling-Number of Bedrooms <br /> 7 Subdivision Name <br /> Block# <br /> ,- <br /> 0 <br /> ❑Public/Commercial-Describe Use .--- <br /> ❑ City of <br /> "....----- CSM Number ❑Village of <br /> ❑State Owned-Describe Use ,A O .L L-A-Ke- <br /> III. <br /> �K� <br /> Town of <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑New System V-Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> 0 Change ❑Permit Transfer to New List Previous Permit Number and D e Issued <br /> B. ❑Permit Renewal 0 Permit Revision of Plumber t <br /> Before Expiration Owner 2.3361 <br /> /2/3 o <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 0 Mound<24 in.of suitable soil <br /> ,lolding Tank ❑Other Dispersal Component(explain) 0 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 /> 70 D — <br /> VI.Tank Info Capacity in Total #of Manufacturer 2 .0o <br /> Gallons Gallons Units •n V. oy <br /> New Tanks Existing Tanks z vn yy <br /> R7 U N 16 N <br /> ncC U inti w c7 0, <br /> e <br /> eSepttFor Holding Tank ao00 p?©oa WOO '2 Gr// 5e..,-- <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 / 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) �i(/ <br /> PO BOX 514,SIREN,WI 54872 <br /> VII.County/Department Use Only <br /> Permit Fee Date Issue Issu�g gent Signature <br /> Approved ❑Disapproved I l A�,�n�� `;y 1 ' r , <br /> 0 Owner Given Reason for Denial <br /> 315° a )),.LQ 4. - <br /> a.Conditions of Approval/Reasons for Disapproval 1ECEfiVE <br /> -411(0111-10 $37,50-0 <br /> --41100 OP S- re i�i741'1fJ MAY 15 2023 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 t42 x 11 fiches in size <br /> Burnett County <br /> Land Services Department <br /> SBD-6398(R. 11/I1) <br />