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County <br /> ( = Safety and Buildings Division r� <br /> _ p _ 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> P 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 lle 9 <br /> purposes in accordance with the Privacy Law,s. 15.04 1 m Stats. I�,t-12 <br /> I. Application Information-Please Print All Information .3. '1-qX '7 <br /> fProperty Owner's Name Parcel# O 7 0 20 .l 916 <br /> o <br /> Property Owner's Mailing Add r Property Location C. <br /> p ea L: N;J/I1� S /�� Govt.Lot i< <br /> City,State Zip Code Phone Number / y4, /4, Section <br /> i �/ /` $�g I� ,� s37� b4 -7 -6 b�S� (circle one <br /> II.Types of Building(check all that apply) Lot# T_�N; R 16 E or <br /> 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use ❑City of <br /> 1 CSM Number ❑ Village of <br /> ! ❑State Owned-Describe Use <br /> i P�Zbwn of <br /> 111. ,Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A, 11 ❑New System Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> i <br /> i i E <br /> B. Permit Renewal 1 ElPermit Revision ❑ Change of Plumber ElPermit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Owner 2'1 N11cmg <br /> 11V.Type of POWTS System/Component/Device: Check all that apply) <br /> j )kNon-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 /> , -7 J o 0 1 <br /> ? V1.Tank Info Capacity in Total I #of Manufacturer <br /> ! Gallons Gallons Units p U �, N <br /> New Tanks Existing Tanks o Y �' <br /> 1 U iin y n is. c7 Q <br /> Septic or I-aW r*-rm9i /oOD Yp D l gQ j� <br /> Dosing Chamber <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 Signatur MP/MPRS Number Business Phone Number <br /> WADE RUFSHOLM / 227691 715-349-7286 <br /> 1 Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX 514.SIREN,WI 54872 <br /> VIII.Coun /De artment Use Only <br /> Approved ❑ Disapprove, Permit Fee Date <br /> Issue J�(f Issuing Agent Signature <br /> ❑Owner Given Reason for Denial <br /> -IX.Conditions of Approval/Reasons for Disapproval <br /> Alf& W s.�mis CE <br /> allow a� cou 14y aJ S-fa.-k re?alet~4S <br /> JUN 0 3 202 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x l I inch n <br /> Wf <br /> Burnett County <br /> Land Services Department <br /> SBD-6398(R. 11/11) <br />