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,.,;0 ; County <br /> 47 Safety and Buildings Division a" 14 f elf- <br /> z <br /> g S 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> ", p Madison,WI 53707-7162 54IN ' 3-21.b <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SAS 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 ��q/ GIBS /�a c f,e <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# D 7 oA y a 3 9 /Y o 7 R <br /> h B L. „TA vedio..vis GroyP LLc_ oa oob 0/l6ov <br /> Property Owner's Mailing Address Property Location 4 31, 1.5 ' <br /> 73 o 9 Ly s&c1 4'lQ ,-Ve 5 Govt.Lot <br /> City,State Zip Code Phone Number y,, /., Section ! <br /> cl <br /> 4 lee in#/�i2it) in A) 3 yaa I/Z .ZJL 6/?o T Se? N; R circle one�,� <br /> IL Type of Building(check all that apply) <br /> Lot# E o W <br /> ''or 2 Family Dwelling-Number of Bedrooms .3 Subdivision Name <br /> Block# <br /> ..--- - r <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of Q <br /> i V 3 a P/3 ° gTown of R qq$ <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> I <br /> A. ❑New System Replacement System ❑ Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> i , List Previous Permit Number and Date Issued <br /> B. ❑Permit Renewal 0 Permit Revision ❑ Change of Plumber ❑Permit Transfer to New <br /> Before Expiration Owner <br /> 1 IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> Non-Pressurized In-Ground ❑ Pressurized In-Ground 0 At-Grade 0 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 /> 1/.5-6 . 7 6 V3 6 .5 d 13,S' <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units c v <br /> New Tanks Existing Tanks v o " 1 8 22 ' <br /> U in cn rn w C7 C. <br /> Septic or Helding.TanlS /de _ `e?'d / /0 d r ev e_,,5 c d <br /> Dosing Chamber <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> I Plumber's Name(Print) Plumber's Signatur MP/MPRS Number Business Phone Number <br /> WADE RUFSHOLM ) 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) (mil/- <br /> PO BOX 514,SIREN,WI 54872 <br /> VIII.County/Department Use Only <br /> )(Approved ❑ Disapproved Permit Fee Date Issue cj Issuing Agent Signature <br /> ❑ Owner Given Reason for Denial '715 /2 I //2 y <br /> IX.Conditions of Approval/Reasons for Disapproval \ _ E C E I /7 E <br /> MPe+ cut' , e-I'baJ-c v <br /> r?7 / r s <br /> know a (ourl 1 s- k APR Z S 20/ t '1_`.- <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 t/2 x 11 inches in size E <br /> Burnett County <br /> Land Services Department <br /> SBD-6398(R. I 1/11) <br />