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:t`m "i,; County <br /> Safety and Buildings Division ,QcT/'nJ ' <br /> 9 S 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> '` P S Madison,WI 53707-7162 � g <br /> 3`/ <br /> r/ `���: <br /> ` ` CS i�.3 "l3 (4,6Rol <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 8386 <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. L Q <br /> I. Application Information—Please Print All Information /80&AJ 'lam/` Lh ke) <br /> Property Owner's Name Parcel# 0 7 O/; . 4/4 / „.7 V <br /> r <br /> G/c I-'/,4 EAJ`� f'e/- S 0 5- 0 0 3 o/%do c„)Property Owner's Mailing Address Property Location 4 c_/ 5 3, <br /> ©7 yy G:-/-_-- Govt.Lot "f 3 <br /> City,State Zip Code Phone Number <br /> /<, /<, Section .77 <br /> nM/8- 1//1-//9" , `5 "5-4? 9 7/5=o?5 97.?5/3 _.(.circle one <br /> II.Type of Building(check all that apply) C f Lot# T yv N; R/ E o1 <br /> X or 2 Family Dwelling—Number of Bedrooms < / Subdivision Name <br /> i Block# <br /> ❑Public/Commercial—Describe Use ❑ City of '.---- <br /> CSM Number ❑ Village of <br /> ❑State Owned—Describe Use G�5 D <br /> V /0,2 S✓� XTown of <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' ❑New lacement System Re y pSystem ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> gList Previous Permit Number and Date Issued <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber 0Permit Transfer to New <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> a-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) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> ‘0 D , 7 S'-5-7 7ae, 9s <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units oo 'b <br /> New Tanks Existing Tanks y a 2 Y s), .g <br /> k L) ' . c.,-, w C7 F. <br /> Septic or Ileidmg Talk ! / ©v 000 / r <br /> ' y_ <br /> Dosing Chamber 0 d d0 (/`� l e'S `e—/� <br /> O <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 / J S 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) lam' rs yC� <br /> PO BOX 514,SIREN,WI 54872 <br /> VIII.County/Department Use Only <br /> 'Approved ❑ Disapproved Permit 5� Date Issued Is ' . Age Sign E c E 11 V -E--1 <br /> 0 Owner Given Reason for Denial 11!21/ia-3 \`v// <br /> IX.Conditions of Ap rova/Reasons for Disapproval <br /> �lil.eC4- a(I a.C45 swk. �'�l'"''^e �3 APR 2 4 2023 0, <br /> Burnett County <br /> Land Services Department <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 inches in size 4 1��Gb <br /> duck -*- 11k1-1,01 <br /> SBD-6398(R. 11/11) <br />