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ar-k ...... Coun <br /> Safety and Buildings Division t4 r 4.; e- <br /> 201 W.Washington Ave., P.O. Box 7162 Sanitary permit Number(to be filled in by Co.) <br /> "' 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 <br /> purposes in accordance with the Privacy Law,s. 15.04 1 m Stats. <br /> I. Application Information-Please Print All Information ICI X t 9�l l D <br /> ` Property Owner's Names Parcel# O 7 <br /> bAA) Re;/M I-J 006 dllo0o <br /> Property Owner's Mailing Address Property Location iaC/ <br /> a 3 S /4 C�'A-A)I_e r 1% rS A /{Q o/ Govt.Lot <br /> City,State Zip Code Phone Number 1 <br /> Sher Lam p sy8l l ) / N W /^> 1� _ Section e <br /> W-r bs/ 3D 7 5�b.� T-J S N; R 1-1E o3 <br /> II.Type of Building(check all that apply) Lot# <br /> V-1 or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> s <br /> Block# <br /> ❑Public/Commercial-Describe Use " ❑City of <br /> CSM Number ❑ Village of <br /> State Owned-Describe Use L1s-Fo Ile f f e_ <br /> Town of <br /> 1II.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A, �New System ❑ Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> i B. � ❑ Permit Renewal El Permit Revision ❑ Change of Plumber ❑Permit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: Check all that a I <br /> i Won-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.Dis ersaUTreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 7 9 5/�v C5 2 <br /> VI.Tank Info Capacity in Total #of Manufacturer c <br /> Gallons Gallons Units ;; c <br /> New Tanks Existing Tanks <br /> c <br /> � U <br /> Septic or HoWirtb Tank /O v /ODDoOe r e S �- <br /> Dosing Chamber <br /> I <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 Business Phone Number <br /> WADE RUFSHOLM 227691 715-349-7286 <br /> i Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX 5I4,SIREN,WI 54872 <br /> VIII.County/De artment Use Only <br /> Approved ❑ Disapproved Permit Fee Date Iss ed Issuing Agent Sign <br /> ❑ Owner Given Reason for Denial <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> pnt <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x.lI inches in size y <br /> 9 <br /> Burnett County <br /> Land Services Department <br /> SBD-6398(R. 11/11) <br />