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County <br /> Safety and Buildings Division t4 r -e..f t <br /> p S 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Vumber(to be filled in by Co.) <br /> `�\ p S Madison,WI 53707-7162 $4/. oN f, <br /> • <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# O 7 0/8 .2 37 l 6 ...746 <br /> t <br /> Acris KNo?;I< 5' ess cs,s3 o/iooe, <br /> Propertyp Owner's Mailing Address 1 Property Location it)e_ , t /n q9 <br /> 6 33 5 JNAi-' L.N Govt.Lot 3 �`�/O <br /> City,State Zip Code <br /> �j Phone Number �/ q � / /4, Section a 6 <br /> !/V 1ih5-le-/" 4.).7. J y�/ 3 608-.33 - / 7/6 r p (circle one <br /> T c.7 / N; R /(� E ort) <br /> II.Type of Building(check all that apply) Lot# <br /> 1 or 2 Family Dwelling-Number of Bedrooms 3 Subdivision Name <br /> Block# ,---- <br /> ❑Public/Commercial-Describe Use ,-..- ❑ City of <br /> ❑State Owned-Describe Use <br /> IQ�p. <br /> ..—� CSM Number ❑ Village of �J <br /> .Town of /f7e.e.,'✓O <br /> /5 3o ? <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' ❑New System I `Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. I ❑ Permit Renewal 0 Permit Revision ❑ Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> PIon-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 AreaRequired(sf) Dispersal Area Proposed(sf) System Elevation <br /> gs"o , 7 6 Y 6 JT <br /> Tank Info Capacity in Total #of Manufacturer i <br /> Gallons Gallons Units ° ' 15-,_5- <br /> VI. <br /> New Tanks Existing Tanks v o .n l A <br /> Septic or 1 iokiiffearAa 7 e, 7 / Zd <br /> Dosing Chamber 7 6 7 5 f / <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 /> /_/ 227691 715-349-7286 <br /> WADE RUFSHOLM �A/ <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 yD a Issu ddn Issuing Agent Signature <br /> ❑ Owner Given Reason for Denial $���� ` ���""�� I }le___ <br /> IX.Conditions of Approval/Reasons for DisapprovalI An �7 <br /> tel alR-h(�rks 4 f ottow n1aink�lanrcilvo;�l�n r1w7 v <br /> i11 E-R <br /> ,94 RieAvavi by xrtic bet 1 cijiiLor t94 APR 2 3 2024 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 r=1 dies in size <br /> Burnett County <br /> Land Services Department <br /> SBD-6398(R. l 1/I 1) Ll« I L 7 $ <br />