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: . County - <br /> Safety and Buildings Division <br /> ` D S 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> t P i Madison,WI 53707-7162 ! ? <br /> C61 —3 l066 ?94 <br /> I 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 95/-� <br /> purposes in accordance with the Privacy Law,s. 15.04 1 m,Stats. <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# p-7 0 <br /> I M $SGG. /UG. 6 D <br /> j Property Owner's Mailing Address Property Location -Tay `D, `-j p 5(1 <br /> 0 6 �J A le /O d Govt.Lot�3 D <br /> City,State r Zip Code Phone Number �/�f h 'A, /4, Section <br /> i bN N-M M/Lcircle <br /> one <br /> II.Type of Building(check all that apply) Lot# T 4 0 N; R E ot� <br /> 111 or 2 Family Dwelling-Number of Bedrooms r Subdivision Name <br /> Block# -- <br /> gPubiic/Commerciai-Describe Use op ❑City of <br /> I ❑State Owned-Describe Use <br /> CSM Number ❑ Village of <br /> Town of SL O <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑New System Neplacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. i [Ell Permit Renewal ❑ Permit Revision El Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner 144449 t $ -7 1989 <br /> IV.Type of POWTS System/Component/Device: Check all that a I <br /> 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 /> I Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Arer Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> Y 7&p 1 /. 6 1 77 33 7, S' 95­ U,*-r1e,-5A <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units c d <br /> New Tanks Existing Tanks c y <br /> U ii) A f% <br /> Septic or Holding Tank e— <br /> Dosing Chamber DO o IQOD /ram (�`. <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 7715-349-7286 <br /> iness Phone Number <br /> WADE RUFSHOLM 227691 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 <br /> VIII.County/Department Use Only <br /> Approved El Disapproved Permit Fee Date Isssued Issuing Agent Signature <br /> cc❑ Owner Given Reason for Denial $ <br /> IX.Conditions of Approval/Reasons for Disapproval 3 <br /> Mee+ au s�as <br /> ;allow p,� coun+y and slak refccife.m� � �� � ��� <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x l l �ht'"'TAAR <br /> 13 <br /> 2024 <br /> Burnett County <br /> SBD-6398(R. I 1/11) Land Services Department <br />