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tite.ar '.� County <br /> V <br /> Safety and Buildings Division <br /> 201 W.Washington Ave., P.O. Box 7162 Sanitary Pe it Number(to be filled in by Co.) <br /> S P Madison,WI 53707-7162 <br /> f 5 ' � <br /> 4711 7 U,,A2/140 <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 �6 �-7 <br /> purposes in accordance with the Privacy Law,s. 15.04 1 m Slats.I. Application Information-Please Print All Information77 <br /> Property Owner's Name Parcel# O -7 6 3.2 .9 /77 S <br /> S C>D-T t3/ DDB <br /> Property Ow er's Mailing Address Property Location pc,/ <br /> .39/ (/ Govt.Lot 3 a� t D 11388 <br /> I City,State Zip Code Phone Number y, '/4, Section 17 <br /> I circle one <br /> In�, J S-1 D �J g.�.Z T N; R E or l) <br /> II.Type of Building(check all that apply) 3 Lot# <br /> 71 or 2 Family Dwelling-Number of Bedrooms Subdivision Name — <br /> Block# <br /> ❑Public/Commercial-Describe Use ❑ City of <br /> ❑State Owned-Describe Use CSM Number El village of <br /> Town of aS W S S <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> i <br /> A. ❑New System t\teplacement 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 Num r and Date Issued <br /> Before Expiration Owner 188 '1/2y I TkI <br /> IV.Type of POWTS System/Component/Device: Check all that apply) <br /> X�on-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 /> 96 <br /> VI.Tank Info Capacity in Total #of Manufacturer c <br /> Gallons Gallons Units <br /> ca c> U v i m <br /> New Tanks Existing Tanks d c ;; a <br /> CC U ) y v1 is, C7 a <br /> Septic or Haldiwg-�Pft <br /> Dosing Chamber D �_ �(� <br /> j 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 G2�,`/Ji 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 /> I Permit Feed Date Issu d Issuing Agent Signature <br /> K Approved ❑ Disapproved <br /> ❑ Owner Given Reason for Denial $ I Z I ZZ Z�� <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Wtr� lY _�e*ack p S PIE C A VE <br /> �011-ow a ) <al <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 inches Ji I size <br /> 4. Burnett County <br /> Land Services Department <br /> SBD-6398(R. 11/1 i) } l tZ✓D a_ �, �� (yg9Z <br />