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_`;r,a-%II„? County n ---._ <br /> Safety and Buildings Division ,Ic3 y/' do O. <br /> p S 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> �` pS Madison,WI 53707-7162 �'.nx 1 ��D��/p <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 3 70 /' 'Talc ID 1{159 <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats.I. Application Information—Please Print All Information • ine.y-e./'S /1D <br /> € <br /> Property�Owner's Name/_ Parcel# 0-7 o,a z Vd3 AS- O/ <br /> p Lr/4 1AS ch.los .5 pg. 003 6/9000 <br /> Property Owner's Mailing Address ` <br /> I Property Location /Q / <br /> t 2 O/ G b ocJ '✓/e) 12/ Govt.Lot ,3 <br /> City,State Zip Code Phone <br /> /Phone Number y, /,, Section <br /> LA.ke ///C In ''OW 157 775 t7�i2" T �/o N; <br /> R / circlE oe n W <br /> II.Type of Building(check all that apply) Lot# <br /> or 2 Family Dwelling—Number of Bedrooms a / Subdivision Name <br /> Block# <br /> —..-- <br /> ❑Public/Commercial—Describe Use _...--- ❑ City of <br /> "� CSM Number ❑ Village of <br /> ❑State Owned—Describe UseI own of �/t}C.K S O <br /> U/ piy9 <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> l A. ❑New System OReplacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> ii <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 4t31o'105 was n0+ I A S-'.0 td,re (au 01 <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) or tg‘nctt SjS4e-r i <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 /> I Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 3a0 . 7 ea? v. -0 7y <br /> VI.Tank Info Capacity in Total #of Manufacturer :: <br /> Gallons Gallons Units p u o 9 <br /> New Tanks Existing Tanks o U z <br /> d E U in ,, i-. 0.c7 / <br /> Septic or Hc{oing-T-ank AO 0 0 moo / xlt ../,'r#td r l <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 (��/ / / 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) Q�i� <br /> PO BOX 514,SIREN,WI 54872 <br /> VIII.County/Department Use Only <br /> Approved ❑ Disapproved Permit Fee Date Is ed Issuing Agent Signature <br /> $ 375 9/3) VZ'/ 4k/,U;iii <br /> ❑Owner Given Reason for Denial <br /> IX.Conditions of Approval/Reasons for Disapproval t\/] '� <br /> fnhe+ •2+bacS v <br /> fouw-' atl cou-n-f'l cnr.� s-ftfc re7(AIre f-s <br /> 1 <br /> 59& 1 ca4r.o+ be loc kd in -a1,� -11.00d-Play APR U 1 2�2�t 1 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x I inc in size <br /> Burnett County <br /> Land Services Department <br /> SSD-6398(R. I 1/l i) $515 ck&, - H (�D1 <br />