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County .�.� <br /> Safety and Buildings Division 4 N t�w�! I <br /> _ 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> Madison,WI 53707-7162 SAKI -.2 3- `[t <br /> l 5D 0 2 <br /> .. CST-�3 -/• <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 govemmental 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 <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. <br /> I. Application Information—Please Print All Information ' <br /> Property Owner's Name Parcel# ci 7 O/8 .2 39/b iZ e <br /> t <br /> \T'e r'e iny p.2.r I < c_.K .5- ,S' 55;2 0/.x2 coo <br /> Property Owner's Mailin Ad,,dr1ess Property Location -t7 j�,h {e / <br /> 7/7$ c tt)e 0 tJ /6 k wy Govt.Lot <br /> City,State Zip Code Phone Number y, %, Section Az <br /> 64)e-654er Lv..4 S %893 763'0?L-42- 74VC6 T 37 N; R l(circle ono <br /> II.Type of Building(check all that apply) Lot# <br /> ;'.j or 2 Family Dwelling—Number of Bedrooms a Z Subdivision Name / <br /> Block# dP►n k � O CB , 'Ad< <br /> _. <br /> ❑Public/Commercial—Describe Use ❑ City of e____, <br /> ❑State Owned—Describe Use r— <br /> CSM Number ❑ Village of <br /> [Town of /2-).9..._e/0 O <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. .New System ❑Replacement System 0 Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑Permit Revision ❑ Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> Jon-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 /> 3 0 o i ,s 4.06 eo0 F6 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units 5 o 5 Y <br /> cAd U U U ,.. y vi <br /> gfNew Tanks Existing Tanks c ,o 8 a <br /> C) rn y i%1. 4":: C7 w <br /> mo/ <br /> Septic or I ns Tank /0 O d — ` oc) / �ierr 14J e.5 C o /� <br /> Dosing Chamber t <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) <br /> PO BOX 514,SIREN,WI 54872 <br /> VIII.County_/Department Use Only <br /> Approved ❑Disapproved Permit Fee,,,,r2 Date Issued Issuing gent Sig ture <br /> ❑ Owner Given Reason for Denial $ 1 y/� /2� [� �] <br /> IX.Conditions of Approval/Reasons for Disapproval EC u v <br /> ome,4- It se . f 5 , ent <br /> ., <br /> APR 2 4 2°23 \ _-)) <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 in hes in size Burnett County <br /> Land Services Department <br /> 4)1426e" ����'� <br /> SBD-6398(R. 11/I1) �/u..Ch- <br />