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;. Kririi.), County
<br /> Safety and Buildings Division d ei/`/tli2
<br /> S P , �; 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.)
<br /> S Madison,WI 53707-7162 73 _ _
<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 339 /
<br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats.I. Application Information-Please Print All Information r �� v r„„,,,/orb,
<br /> Property Owner's Name r ; S p _ Parcel# p 7 0/,.? o7 ye. 4 /3.--,6.--
<br /> 7n€1 V�/� T e/,se•J >,, /5- 7j. c, 1 o
<br /> Property Owner's Mailing Address " 'Property Location
<br /> op
<br /> LJ o/�' 37� Govt.Lot
<br /> City,State I, Zip Code Phone Number /<, , f,�
<br /> s�;A ✓ le m a 6,/ �y ,
<br /> /<, Section
<br /> 7 08 y 374 -30� 3y7C circle one
<br /> II.Type of Building(check all that apply) Lot# T �� N; R / E
<br /> 'Si or 2 Family Dwelling-Number of Bedrooms y'.S/ Subdivision Name//
<br /> Block# ,/!/ e!'b/al �""�� V❑Public/Commercial-Describe Use
<br /> ❑ City of -
<br /> ❑State Owned-Describe Use —_ CSM Number ❑ Village of
<br /> -- STown of --f} -KS o/t)
<br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable)
<br /> A. A New System 0 Replacement System ❑Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain)
<br /> B. ❑ Permit Renewal ❑ Permit Revision 0 Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued
<br /> Before Expiration Owner
<br /> IV.Type of POWTS System/Component/Device: (Check all that apply)
<br /> $Non-Pressurized In-Ground 0 Pressurized In-Ground ❑At-Grade 0 Mound>24 in.of suitable soil 0 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 /> vSa . 7 6 s'3 6 s-'a 7v,...s---
<br /> VI.Tank Info Capacity in Total #of Manufacturer
<br /> Gallons Gallons Units .a o ,Ub, 0
<br /> Rt U V I.+ �
<br /> New Tanks Existing Tanks y s,o p y , A
<br /> Septic or H.,iding Tack / ,00 /4000 / ^}-r let4`I rA-i-el_ 7-
<br /> Dosing Chamber -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) Plumbefr's Signature MP/MPRS Number Business Phone Number
<br /> WADE RUFSHOLM te�(/Gc„p`_Qv 227691 715-349-7286
<br /> Plumber's Address(Street,City,State,Zip Code)
<br /> PO BOX 514,SIREN,WI 54872
<br /> VIII.County/Department Use Only
<br /> Approved ❑ Disapproved Permit Fee e � Date����d I ui g ent��❑Owner Given Reason for Denial 5 6///
<br /> IX.Conditions of Approval/Reasons for Disapproval u I 0. 421
<br /> oleo_ 4,11 ,fib .F :ienif�s rr E, EcEllvET1
<br /> ?kkmhe 1 4ei 045a6,11 *4d 5 13 @ GZ7 10ad�!�
<br /> N , n ' v� r :n G- 14 ire 4.. _
<br /> �� W, h 5 off. �rI y t1Y 2 5 2023 V)
<br /> Attach to comp a plans for the system and submit to the County only on paper not less than 8 1/2 x u in es ins e
<br /> Burnett County
<br /> Land Services Department
<br /> SBD-6398(R. 11/11)
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