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`%..,h:r,P;, County <br /> Safety and Buildings Division ,u/`A) 2.1* <br /> Q _ 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> N. p Madison,WI 53707-7162 SAN-214 _ 3 2 <br /> CA -o2Lf_- 2 9 40540 ? <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 ProjectAddress(if different than mailing address) <br /> the Department of Safety and Professional Servies. Personal information you provide may be used for secondary 416.1 5- <br /> -purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. /� <br /> I. Application Information-Please Print All Information • *...S/9'1 p Ar <br /> Property Owner'& ingA <br /> me Parcel# p 7 op/ / 2 3$ /SG Y <br /> K,IPerry 5"is /A7 aii4.00 <br /> Property Ownerddress Property Location -ray_ `b: tQ223 <br /> -R ao0M ,�V9 !J <br /> Govt.Lot <br /> City,State Zip Code Phone Number -re.cry y, /., Section <br /> S©th a, s,c.t w.� 5 (-/da 5 igys_.3A3-7y43 `I' 33' N; R / irclEonb <br /> H.Type of Building(check all that apply) Lot Vi-er 2 Family Dwelling-Number of Bedrooms rD Subdivision Name <br /> Block# 11, ,d pf f"er /9L✓"e 5 <br /> ❑Public/Commercial-Describe Use ❑ City of <br /> l CSM Number ❑ Village of <br /> ❑State Owned-Describe Use �7 <br /> g,Town of �!Q 4 //ei7C'. <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. I,New System 0 Treatment/Holding❑ Replacement System Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑Permit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> E <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> IANon-Pressurized In-Ground 0 Pressurized In-Ground 0 At-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> 0 Holding Tank 0 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 /> ysa y5—; -7 <br /> 30 a , � ya�� <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units , 0 o :,, <br /> cC U C..) V L. y <br /> New Tanks Existing Tanks o a.) 8 p 2 2 <br /> Septic or Hclrliaenk / ey0 )c td+ r e <br /> Dosing Chamber �D 00 `/ <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 a / 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) ��j�P� <br /> PO BOX 514,SIREN,WI 54872 <br /> VIII.County/Department Use Only <br /> Approved ❑ Disapproved Permit Feed Date Issued ttJJ Issuing Agent Signature <br /> i ❑ Owner Given Reason for Denial $ �� J I�'2�2-1 J <br /> IX.Conditions of Approval/Reasons for Disapproval;let+ ca( Sc aokS k,llow aU Coin( owl S-la-k ret re" 14 IECEIJTED <br /> 1 l MAR 0 6 2024 <br /> 1, <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 r/2 x 1 inches in size o <br /> Burnett County <br /> /, Land Services Department <br /> SBD-6398(R. 11/11) 4y26 av k 11Qigt2 <br />