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Coun <br /> _titlah <br /> Safety and Buildings Divisionrhp <br /> S 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> �+ PS Madison,WI 53707-7162 3Pw-2��2 <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 Slats. <br /> I. AP iication Information-Please Print All Information <br /> Property Owner's Name Parcel# --5 <br /> 14� n r�� o/? /5-� !-6916200 <br /> roperty Owner's Mailing Address Property Location I/' -10 <br /> ' 1 <br /> l / Govt.Lot .� �� <br /> City,State Zip Code Phone Number <br /> y, /<, Section <br /> _3 Z67 17 (circle one <br /> l! T�0N; R�[�Eor(V) <br /> II.Ty#of Building(check all that apply) Lot# <br /> ❑1 or 2 Family Dwelling-Number of Bedrooms <br /> Subdivision Name <br /> Block# f'-QJ�70Y-�- /L5� fl � <br /> T <br /> ❑Public/Commercial-Describe Use ❑ city of <br /> ❑State Owned-Describe Use CSM Number El Village of <br /> Town of <br /> j III.'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 /> B• ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner I N V <br /> IV.Type of POWTS System/Component/Device: Check all that apply) <br /> i <br /> i Non-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 /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units <br /> New Tanks Existing Tanks q V <br /> � U <br /> septic or del ±-ink !O D O /OV D �-�u��7` d✓ <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) Plumber's Signature MP/MPRS Number Business Phone Number <br /> WADE RUFSHOLM /�i 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 <br /> i <br /> VIII.County/De artment Use Only <br /> I wQ Approved ❑ Disapproved Permit Fee GDate Issued Issuing Agent Signature <br /> ❑ Owner Given Reason for Denial I L — ✓/i I Z�Z 5 <br /> IX.Conditions of Approval/Reasons for Disapproval _r <br /> ; <br /> I follow aV ca,1�4 y <br /> p� S-�t� ref it <br /> 1 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 112 x tt inches in size <br /> Burnett County 9 <br /> Land Services Department j <br /> SBD-6398(R. I I/11) j,2GJU0 c)ALck�d-- 11)Z& <br />