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i;•�x r �.�., Coun <br /> Safety and Buildings Division <br /> t D S K1 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> " \ P S Madison,WI 53707-7162 5AN <br /> ' (05L0 At; <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 o771 9 �y9 y��/�Q <br /> purposes in accordance with the PrivacyLaw,s. 15.04 1 m,Stats. v <br /> I. Application Information—Please Print All Information <br /> Property Owner's Name Parcel#0'7 Oa 8 v? V47 t1l WO <br /> m ReaI E"sIA-fe. LAG / o o// ov <br /> Property Owner's Mailing Address r ' f Property Location <br /> --5--/ a371 V e- &I Govt.Lot <br /> City,State Zip Code Phone Number ,/a , <br /> // E /<, Section � <br /> _5 A-C- it1, 5:5-0 `7 `I 65/ 3-76 Q (circle one <br /> II.Type of Building(check all that apply) Lot# TQ_N; R /7 E o> <br /> or 2 Family Dwelling—Number of Bedrooms 3 Subdivision Name <br /> _ Block# <br /> ❑Public/Commercial—Describe Use ❑ City of <br /> ❑State Owned—Describe Use CSM Number ❑ Village of <br /> I--- XTown of <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. Agew System ❑Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑ 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 /> .qrNon-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 Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> so , 7 6 y13 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units p c <br /> New Tanks Existing Tanks 0c y; <br /> f� U <br /> Septic or Hetdtng'Nnk OD !�O D f <br /> Dosing Chamber Q O Q� <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 /> WADE RUFSHOLM ate(`/' 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 /> Approved ❑ Disapproved Permit Fee Date Issued? Issuing Agent Signature <br /> El Owner Given Reason for Denial $4 � �lJ Y r� <br /> IX.Conditions of Approval/Reasons for Disapproval�x�� 11 (ol <br /> ���/►'lee'- ��� S 5 W� <br /> ;!s <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1n x I h i siz ,i' ^!1 +� <br /> ���� 1 1 �iaa3 <br /> Burnett County <br /> SBD-6398(R. I I/I 1) Land Services Department <br />