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County <br /> Safety and Buildings Division w W g, <br /> 0 201 W.Washington Ave., P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> P Madison,WI 53707-7162 <br /> 6K 4997 <br /> —10 <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 /> Property Owner's NaTe Parcel# p 7 p o;70 aZ <br /> /e, C2 Z5 0 0 0 V d OD Q/.34od <br /> Property L ailing Address Property Location 3 Z <br /> Govt.Lot <br /> City,State Section v Zip Code Phone Number %,, pG <br /> / s F �,, U <br /> •�b y!' ui.� s 93 0 7%�S�6 o Y 97 (circle one <br /> ! II,Type of Buil ng(check all that apply) Lot# T �� N; R _E o <br /> CV <br /> �1 or 2 Family Dwelling-Number of Bedrooms PC/ / Subdivision Name <br /> f _ Block# '- <br /> ❑Public/Commercial-Describe Use ❑ City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of <br /> 1/ 3 KTown of <br /> 1111.Type of Permit: (Check only one box on line A. Complete line B if applicable) J <br /> A. ❑New System .Replacement System ❑ Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> I <br /> i <br /> i <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 /> a <br /> i IV.Type of POWTS System/Component/Device: Check all that apply) <br /> ANon-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑ Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> 13 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 /> !1 VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons _ Gallons Units <br /> I <br /> C U U U ti <br /> New Tanks Existing Tanks o y a <br /> r U v u 0 a.. <br /> Septic or Hvtd1ffg9'lank <br /> I Dosing Chamber <br /> •IIII.Responsibility Statement- 1,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 7z"Iz— 227691 715-349-7286 <br /> i Plumber's.Address(Street,City,State,Zip Code) <br /> 1 PO BOX 514,SIREN,WI 54872 <br /> aJII .Coun /De artment Use Only <br /> Approved ❑ Disapproved Permit Fee Date Issued u n Age Si ature <br /> ❑ Owner Given Reason for Denial <br /> Ix.Con itions of A-pIp-Irov I/Reasonss for Disapproval <br /> Imee A II 5�' G S -t 1r ".-Vmt <Al j D F. <br /> APR 17 2023 <br /> I <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 ocher <br /> Burnett County <br /> Land Services Department <br /> SBD-6398(R. 11/11) (, # ' (Q3170 <br /> rrll�G <br />