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County I _ <br /> _,7 Safety and Buildings Division r�� <br /> 201 W.Washington Ave., P.O. Box 7162 <br /> _ g Sanitary Permit Number(to be filled in by Co.) <br /> p Madison,WI 53707-7162 � <br /> Sanitary Permit Application State Transaction Number <br /> it 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 L/g 4/g' <br /> purposes in accordance with the PrivacyLaw,s. 15.04 1 m,Slats. <br /> `7 <br /> <. Application Information-Please Print All Information <br /> Property Owner's Name I Parcel# p 7 p / a s <br /> ?roperty dner's Mailing Address Property Location <br /> r 7, +A) A v'e- 5 Govt.Lot <br /> Ci y,State Zip Code Phone Number /4, /4, Section <br /> o/(� D S� 3�8 ucle one) <br /> T <br /> T N; R E o�i, <br /> H.'Type of Building(check all that apply) Lot# <br /> or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block# ��(,�e. <br /> I `l?ubl is/Commercia!-Describe Use _ ❑ City of <br /> E <br /> ❑Village CSM Number age of <br /> L State Owned-Describe Use �+ <br /> Town of L;/d T O l Q <br /> HI.Tyree of Permit: (Check only one box on line A. Complete line B if applicable) <br /> ❑New System Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> s <br /> IPermit Renews! ❑ Permit Revision ❑ Change of Plumber ElPermit Transfer to New List Previous Permit Number II d Date Issued <br /> Before Expiration Owner 2 0M 10121 {1% <br /> ! N.Type of POWTS S stem/Corn onent/Device: Check all that apply) <br /> %Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑At-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> lJ lioiding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> Y.Dispersal/Treatment Area Information: <br /> Design.Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> Soo ` . 7 ya �� o <br /> V-.'7,-r,i(info Capacity in Total #of Manufacturer i <br /> Gallons Gallons Units a §! �j y <br /> New w Tanks Existing Tanks Y <br /> r� U y ti s. C7 A <br /> Septic or Ho?ding Tank <br /> Dosing Chamber �-OO <br /> ` U.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> ?lumber's Name(Print) Plumber's Signature MPIMPRS Number Business Phone Number <br /> WADE RUFSHOLM e 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO BCX 514,SIREN,WI 54872 <br /> V111,County/Department Use Onl <br /> A ❑ Disapproved Permit Feed <br /> .7 Date Issued Issuing Agent Signature <br /> Approved i $ — (f <br /> Owner Given Reason for Denial t <br /> 1X Conditions of Approval/Reasons for Disapproval RAW L IQ:5D <br /> 07d S*4 r-efall&W'11-5 <br /> !," 21 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 inchm n" <br /> Burnett County <br /> Land Services Department <br /> SBD-6398(R. i i/11) <br />