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- Safety and Buildings Division f c4 (u i en" <br /> D 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 A LP2y7 <br /> -0' CST.ALL---20 7 ((2..L D3 <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 / <br /> you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. 51 6 spie1, ,C-J,l•J� <br /> I. Application Information-Please Print All Information • <br /> Property Owner's Name Parcel# 6 7 OD 6 a 3S /7 D 3 <br /> •ZI/4/I1e Sow w ,if r6u7 y o 3 ooa 0 ;260e <br /> Property Owner's Mailing Address �� Property Location <br /> c/►uX.tD l8(02 <br /> 7443 2 C e rn e fe C y Govt.Lot <br /> City,State Zip Code Phone Number s G.) y,s. y4, Section 3 <br /> C !` _ 1 98,7� circle one <br /> J it.nJ 7 o T -38 N; R E o>� <br /> II.Type of Building(check all that apply) Lot# <br /> ❑ I or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> e—' <br /> Block# `® <br /> ❑Public/Commercial-Describe Use .--- <br /> 0 City of <br /> CSM Number 0 Village of ---------- <br /> State Owned-Describe Use //�� <br /> own of cL / 4 , -S <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ANew System 0 Replacement System 0 Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <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 <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> 41on-Pressurized In-Ground 0 Pressurized In-Ground 0 At-Grade 0 Mound>24 in.of suitable soil 0 Mound<24 in.of suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(se Dispersal Area Proposed(sf) System Elevation <br /> y�a • 7 ZY.3 �sd q6, 5 <br /> VI.Tank Info i Capacity in Total #of Manufacturer d <br /> Gallons Gallons UnitsoNew Tanks Existing Tanks 2 .°o ii <br /> t. <br /> ct U i%n . 'col w C7 i% <br /> Septic or Holdirterr n'k /0 b D .`- /©DD l A)8 r we 5 cia <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 Si ature MP/MPRS Number Business Phone Number <br /> WADE RUFSHOLM ♦ / 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) fit/ <br /> PO BOX 514,SIREN,WI 54872 <br /> VIII.County/Department Use Only <br /> Approved ❑ Disapproved Permit FeeDate Issued Issuing Agent Signature <br /> ❑Owner Given Reason for Denial $ I `�Fe I 2,'20�� C���t�./�' p <br /> "' <br /> IX.Conditions of Approval/Reasons for Disapproval I /ry =� <br /> � QV Sc5 i v <br /> law a,U Coup aid Sit r lifeM 1h ; <br /> �! �`1 SIC <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 1 Tocl es in size <br /> Burnett County <br /> Land Services Department <br /> 4! 5Z9 <br /> SBD-6398(R. 11/11) Ciht tka 1tp939 <br />