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;ci as ar,,i, Coun <br /> Safety and Buildings Division /0 urioatIL <br /> 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 •(_23_ C 1 Q �� 5 <br /> n' /,`o,,: - CQJ t:-e 3 too <br /> State Transaction Number <br /> Sanitary Permit Application <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 I <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. �f�� d_�� R'/ <br /> I. Application Information-Please Print All Information • s/0o/' . "`/// <br /> Property Owner's Name Parcel# 6.7 to/,j .2 y0 /5'f/ $- <br /> R 0 Ler� /--Ipci57)1A-•L) 7-7-us7 /s 7// er7000 <br /> Property Owner's Mailing Address Property Location <br /> 7 4/57, P/N e. 13e/u 0/ Govt.Lot <br /> City,State Zip Code Phone Number y, /<, Section <br /> �/�D/'6 aOl�� � ,7� � 3�/ or� d1S a27 351,c6 circle one <br /> II.Type of Building(check all that apply) Lot# T �� N; R (� E o <br /> pif-l-or 2 Family Dwelling-Number of Bedrooms 3 y9 Subdivision Name <br /> Block# 5fsi(#) �.4-de, J qwl %F B Vk4 <br /> ❑Public/Commercial-Describe Use ---- <br /> 0 City of .-- - <br /> ❑State Owned-Describe Use <br /> �� CSM Number ❑ Village of <br /> Town of NTAGXSa.✓ <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' 0 New System Re lacement System ❑Treatment/HoldingTank Replacement Only ❑Other Modification to ExistingSystem(explain) <br /> Y �. P Y P Y ( P ) <br /> B. ❑ Permit Renewal ❑ Permit Revision 0 Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner 100S 7 <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> KNon-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 /> V.5-0 , '7 6 y3 ‘5-0 ps <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units V o ro S? <br /> New Tanks Existing Tanks ,. 8 2 y .o 1aU 1y c) iwC7 a <br /> Septic or Holding-rank /eP o o /oov / 'Aifq 117%9---0 I% <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) Plum S re MP/MPRS Number Business Phone Number <br /> WADE RUFSHOLM 04 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 Li -5 7Po%3 T Permit Fee Date Issued I s i ent ignature <br /> ❑Owner Given Reason for Denial C V g <br /> IX.Conditions ppf Approval/Reaso s for Disapproval <br /> 61e4 ll .5e-{-�D,1.c -( S f .tPo1-S JUL 0 3 2023 <br /> Burnett County <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 In x ILlitalileartates Department <br /> I ( 'ql <br /> SBD-6398(R. 11/11) 4) "1 5'""r <br />