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• <br /> �'ir `t+,; County <br /> Safety and Buildings Division ,� r Ai <br /> D S �, 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> 1 PS Madison,WI 53707-7162 .23,.22 <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 1— 1 D ;.1595 <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. //� // `� <br /> I. Application Information-Please Print All Information °I VTC'`j 56 <br /> PropertyOwner's Nam Parcel# et 7 L.,Sot �7 .7'/'S 2C.5— <br /> Db�-;r C,4m p €-// <br /> 05 00 05/ooC� <br /> Property Owner's Mailing Address Property Location ,O c/ <br /> / / be e f /6/ Govt.Lot 42 <br /> City,State Zip Code Phone Number , ! <br /> (/ /<, <br /> h, Section <br /> �/41�f�/Q- n , /L� `J b/401 51--�7�-3 3 3g (circle one <br /> II.Type of Building(check all that apply) Lot# T N; R / E oW <br /> %1 or 2 Family Dwelling-Number of Bedrooms 2 . Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use — <br /> ❑City of -'- <br /> ❑State Owned-Describe Use CSM Number ❑ Village of <br /> V C' p'2/ 7 grTown of . /S_.5 <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. New System ❑ Replacement System <br /> y p y ❑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 /> YNon-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 /> ..ov , -7 '�1 y.3 t) <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o •,b, <br /> New Tanks Existing Tanks y o v TiS i ra <br /> krU rn y v, w 3 E <br /> Septic or Hvhifng-enk / 7c2O /©ex, / /1)0 r G 'C'-5 G G !� <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 / f 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 <br /> VII .County/Department Use Only <br /> Permit Fee !� Date Issued Issuing gent S. a e <br /> Approved ❑ Disapproved <br /> ❑ Owner Given Reason for Denial S VS l'/*l�',3 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Pleel- till (Gt,n f s 4C- r ./e,we ti3 C 11 1-1 13 21 <br /> iJ <br /> ECEWED <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 I c n siApR 2 8 ZDZ3 <br /> Burnett County <br /> SBD-6398(R. 11/11) Land Services Department <br />