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Co <br /> Safety and Buildings Division y� <br /> 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> �l S `"' Madison,WI 53707-7162 <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 Slats. <br /> I. Application Information-Please Print All Information <br /> I Property Owner's Name Parcel# a'I pap W 6 O 7 S' <br /> R'e. z r S 66o v -o 00 <br /> Property Owner's MailIng Address l Property Location TC�Y `p 14353 <br /> Lc/ Govt.Lot <br /> City,State .. II Zip Code Phone Number y, 1/4, Section_ 7 <br /> Q. /1/J !1/. S`,�D / J? (circle on <br /> b25 6/9 �T D N; R�Eot� <br /> II.Type of Building(check all that apply) Lot# <br /> 41 or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> f <br /> I Block# I /` Q <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of � <br /> ❑ V <br /> El State Owned-Describe Use CSM Number illage of <br /> R-Town of <br /> 111.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A, ❑New System Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> i B. � El Permit Renewal ❑ Permit Revision ❑Change of Plumber El Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration ( Owner 312S Wc I9$8 <br /> IV.Type of POWTS System/Component/Device: Check all that a 1 <br /> KNon-Pressurized In-Ground ❑Pressurized In-Ground ❑ At-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> I <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dis ersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 7ank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units a § c <br /> New Tanks Existing Tanks c <br /> Un rn u C7 0. <br /> Septic or I Eeiding +k O — D D <br /> Dosing Chamber 6 ig o �� ��� <br /> i <br /> I 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 N /MPRS Number Business Phone Number <br /> WADE RUFSHOLM 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 <br /> VIII.County/De artment Use Only <br /> i Permgit Fee Date Issuedl� Issuing Agent Si re <br /> " \Approved ❑ Disapproved <br /> Owner Given Reason for Denial $�G II <br /> IX.Conditions of Ap roval/Reasons for Disapproval ZS <br /> s�k (e w���� n <br /> E IS <br /> c ab� J" <br /> Attach to comp) to pla s for the system and submit to the County only on paper not less than 8 t/2 x 11 iples iasize <br /> Burnett County <br /> Land Services Department <br /> SBD-6398(R. 11/11) <br />