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/ <br /> County <br /> Safety and Buildings Division //`/)/ i/vee, <br /> ~ ' D S _ 201 W.Washington Ave., P.O. Box 7162 Sanitary Permitit Number(to be filled in by Co.) <br /> P Madison, WI 53707-7162 S14N`24--6 <br /> CS-r-zii• of ����� <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 <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'Name r Parcel#Q 7046 a2 3 8 /7 023 <br /> It /5 5..-404iS e"--) .2 ®/ oo0 o/%oov <br /> Property Owner's Mailing^Address Property Location <br /> Y Oy / 1,J,4/5 cJO r/ ? p J Govt.Lot <br /> City,State Zip Code Phone Number /` , `, ) , �3 <br /> 7 /4, /4, Section <br /> .s/ce./(/ tt/.1" .S y8'7� 377 ?/ (circle one <br /> II.Type of Building(check all that apply) Lot# T sS N; R t'] E o <br /> XI or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block# — <br /> ❑Public/Commercial-Describe Use - <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number CI Village of <br /> V--Town of Off-.v/e./.5 <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑New System Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal 0 Permit Revision ❑Change of Plumber ❑Permit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Owner Ule 3 1 <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) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units a o'n 2 <br /> New Tanks Existing Tanks d c v Y .~moo <br /> 0 <br /> uE U cn , c, w C7 0, <br /> Septic or HeldlttrFank /O o /ODd r <br /> Dosing Chamber 6o d — /Pe / LJ/C. J C. X <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumb s Si nature 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 Date Issued , Issuing Agent Signature <br /> ❑ Owner Given Reason for Denial $ t <br /> 125 t ` g/zoV-/ •=etAllit� <br /> IX.Conditions of Approval/Reasons for Disapproval g <br /> f a t hads Cat l taa <br /> [-ollol'U to canny old sic atr,d'et-14.001,s j E C E [1 V I <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%es Nji 0 8 2024 <br /> SBD-6398(R. 11/11) Burnett County <br /> Land Services Department <br />