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.`fi-•ax r -v',.,., Coun� <br /> Safety and Buildings Division u J`K9 2. <br /> D s 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> \ P 1 Madison,WI 53707-7162 <br /> •`7_ F�_ S_ e s A 23- II-3 (oSI Cg <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's Name Parcel# 0 7 CS a ei .1'9 /ya8 <br /> e n) ! 6/4_55elf 9 o 1 o ao o/jeci a <br /> Property Owner's Mailing Address — Property Location , I b ZIh <br /> `f V D R0////U,5 G r C e✓AJ l C/ Govt.Lot <br /> City,State Zip Code Phone Number Se- /4, , Si <br /> `� �/ '/ .SLJ /<, Section �' <br /> 5 P o o e r- 4t) I S h c 7/3 y7/ /Y�7d I(9ircle one <br /> II.Type of Building(check all that apply) Lot# T c�� N; R /5+ E o� <br /> 11 or 2 Family Dwelling—Number of Bedrooms 3 Subdivision Name <br /> Block# <br /> ❑Public/Commercial—Describe Use __.-- <br /> 0City of <br /> ❑State Owned—Describe Use ----- CSM Number ❑ Village of <br /> 2Krown of R U.5 le <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' 0 New System $&eplacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. 0 Permit Renewal ❑ Permit Revision 0 Change of Plumber 0 Permit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> %Non-Pressurized In-Ground ❑Pressurized In-Ground 0 At-Grade ❑Mound>24 in.of suitable soil 0 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(se Dispersal Area Proposed(se System Elevation <br /> yso • -7 6 v.3 �o 7C, s <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units 1, ° o <br /> New Tanks Existing Tanks c <br /> Septic or Heiding-Tanl', /D D'v f f/OD0 / � ) e-s e. <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 ttiGte,L. <br /> 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 09 Date Issued tgent atu <br /> ❑ Owner Given Reason for Denial $375_� 7/0 l?-3 <br /> IX.Conditions of Approval/Reas ns for Disapproval <br /> Ailk- al Set c 4 'de. E C E {I V E 0 <br /> JUL 0 7 2023 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 tr.l clil <br /> es in size <br /> Burnett County <br /> l <br /> Land Services Department <br /> fit' <br /> SBD-6398(R. 11/11) ( am? 4375- <br />