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Coun <br /> _- Safety and Buildings Division Vt.I('AJ� <br /> ` Els _ 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> P Madison,WI 53707-7162 !r,, 1 a�_ <br /> v'iTly <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 r�?& -.5- <br /> purposes in accordance with the Privacy Law,s. 15.04 1 m Slats. <br /> 1. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# 0-7 O y <br /> Property Own is Mailing Address Property Location Pc- <br /> I Qy-bD 7Ly 10 <br /> 1 ovo c eJAr Dr, A)LJ Govt.Lot <br /> City,State Zip Code Phone Number y, <br /> (/ I /4, Section <br /> { (�A`• �Otl �SO 1 ! 763 ,V Y 6 r y 9 (circle one <br /> 11.Type of Building(check all that apply) Lot# T N; R E o <br /> ' Subdivision Name <br /> :i or 2 Family Dwelling-Number of Bedrooms _ <br /> f Block# <br /> j ❑Public/Commercial-Describe Use <br /> !( El city of <br /> ❑ CSM Number Village of <br /> State Owned-Describe Use <br /> ❑ <br /> �/3f ?23 Town of l�s� <br /> V <br /> � <br /> i 111.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' ❑New System /�R'eplacement System ElTreatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> I <br /> B. f� ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber ElPermit Transfer to New List Previous Permit Number and Date Issued <br /> I + Before Expiration Owner 4h 2 iLP S'-7 1992. <br /> ' IV.Type of POWTS System/Component/Device: Check all that apply) <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 /> 1 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 /> `IL'wank Info ` Capacity in Total #of Manufacturer <br /> Gallons Gallons Units c <br /> New Tanks Existing Tanks y <br /> i tS~ U ti w C7 a <br /> Septic or uai� <br /> Dosing Chamber <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plu er's Signature MP/MPRS Number Business Phone Number <br /> i WADE RUFSHOLM 227691 715-349-7286 <br /> i <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 <br /> i <br /> V1I1.County/Department Use Only <br /> Approved El Disapproved $e3 t Feed Date Issued Issuin Agent Si ature <br /> ElOwner Given Reason for Denial i5 <br /> IX.Conditions of Approval/Reasons for Disapproval -7111 <br /> EGMYE <br /> dlow Q,l,► c l�y a, �hc- r��u�re <br /> n Mp 7 R <br /> In <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x I I Jn in size <br /> Burnett County <br /> Land Services Department <br /> SBD-6398(R. l l/1l) <br />