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/f`rnxiie�� <br /> Industry Services Division County <br /> 4822 Madison Yards Way <br /> umett <br /> Madison,WI 53705 Sanit <br /> ary Permit Number(to be filled in by <br /> P.O.Box 7302 Co.) <br /> Madison,WI 5302 �.Z3 <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 is <br /> required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are submitted to the Project Address(if different than mailing <br /> Department of Safety and Professional Services.Personal information you provide may be used for secondary address) <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Slats. same24740 FOSMO DR <br /> I.Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> STEVEN M&BARBARA E BOLLUM 07-014-2-38q-15-04-5 05-003-013000 <br /> -a : 125t0 <br /> Property Owner's Mailing Address Property Location <br /> 3141 12ST NW <br /> Govt.Lot <br /> City,State Zip Code Phone Number <br /> NEW BRIGHTON MN 55112 612-590-6643 y, /<, Section 4 <br /> 11.Type of Building(check all that apply) Lot# T 38 N R 15 W <br /> ❑x 1 or 2 Family Dwelling-Number of Bedrooms 3 2 Subdivision Name <br /> ❑Public/Commercial-Describe Use Block# LOT 2 <br /> ❑State Owned-Describe Use ❑City of <br /> CSM Number ❑Village of <br /> SM V 1 P 64 x❑Town of_LAFOLLETTE <br /> Ill.Type of POWTS Permit:(Check either"New"or"Replacement"and other applicable on line A. Check one box on line B.Complete line C <br /> if applicable.) <br /> A. ❑New Replacement System X Other Modification to Existing System(explain) (explain) <br /> ❑ Additional Pretreatment Unit <br /> System Tank Addition <br /> B. X Holding In-Ground ❑ At-Grade Mound ❑ Individual ❑ Other Type(explain) <br /> (conventional) <br /> Tank Site Design <br /> C. ❑ Renewal ❑ Revision ❑ Change of Plumber ❑Transfer to New Owner List Previous Permit Number and Date <br /> Issued <br /> Before <br /> Expiration <br /> IV.Dispersal/Treatment Area and Tank Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpd/sf) Dispersal Area Required(sf) Dispersal Area System Elevation <br /> l Proposed(sff) <br /> 1 �- <br /> Capacity Total #of Manufacture <br /> Tank Information in Gallons Units = <br /> Gallons U N <br /> New <br /> U n Existing Tanks � � � � � <br /> Tanks <br /> Septic or Holding Tank x x 000/2000 ieser <br /> Dosing Chamber <br /> V.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Sjgnature MP/MPRS Business Phone Number <br /> Luke Schmitz i Number 715-520-2434 <br /> 884121 <br /> Plumber's Address(Street,City,State,Zi ode) <br /> Po Box 160 Shell Lake WI 54871 <br /> VI.County/Department Use Only <br /> Approved ❑Disapproved Permit Fee Date Issued Issuing Si ature� <br /> ❑Owner Given Reason $ 375° zlv 12m �7for Denial nn C v IE <br /> d RILuz o u com+i aw( S44 ✓-elk ikj-7 74:S NOV 0 8 2023 <br /> Pas+ 30 a Ai a ffrWvX , k)o_- i n 5 -Rw "R4AMf-L -0 Burnett County <br /> CD�[4 �+ waS ricet112d Land Services Department <br /> �2�2t�2tsL3 <br />