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} `,.� <br />� <br />Industry Services Division <br />County <br />Burnett <br />Sanitary Permit Number (to be filled in by Co.) <br />r y <br />1400 E Washington Ave <br />iCrP.O. <br />Box 7162 <br />Madison, WI 53707-7162 <br />Sanitary Permit Application <br />State Transaction Number <br />In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental unit <br />AM <br />Project Address (if different than mailing address) <br />is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are submitted to <br />the Department of Safety and Professional Servies. Personal information you provide may be used for secondary <br />1673 Evergreen Path <br />purposes in accordance with the Privacy Law, s. 15.04 1 m , Stats. <br />I. Application Information - Please Print All Information <br />Property Owner's Name <br />Parcel # <br />William Rice <br />07-024-2-39-14- lq-a 01-000-0/5600 <br />Property Owner's Mailing Address <br />Property Location <br />39814 Nez Perce Ln <br />Govt. Lot <br />NE y,, NW /a, Section 14 <br />City, State <br />Zip Code Phone <br />Number <br />North Branch MN 55056 <br />(circle one) <br />T 39 N; R 14 E or W <br />II. Type of Building (check all that apply) Lot <br /># <br />Subdivision Name <br />Q 1 or 2 Family Dwelling - Number of Bedrooms 2 5 <br />Block <br /># <br />❑ Public/Commercial - Describe Use <br />❑ City of <br />❑ State Owned - Describe Use CSM <br />❑ Village of <br />Number <br />19/41 <br />Q Town of Rusk <br />III. Type oS Permit: (Check only one box on line A. Complete line B if applicable) <br />4'OVNew <br />System <br />y <br />❑ Replacement System <br />p y <br />❑ Treatment/Holding Tank Replacement Only <br />El Other Modification to Existing System (explain) <br />B. <br />❑ Permit Renewal <br />❑ Permit Revision <br />❑ Change of Plumber <br />❑ Permit Transfer to New <br />List Previous Permit Number and Date Issued <br />Before Expiration <br />Owner <br />IV. Type <br />of POWTS S stem/Com onent/Device: Check all that apply) <br />Q 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. Dis ersal/Treatment Area Information: <br />Design Flow (gpd) I <br />Design Soil Application Rate(gpdsf) <br />Dispersal Area Required (so <br />Dispersal Area Proposed (so <br />System Elevation <br />450- 380 1.7 <br />429 <br />440 <br />196.5 <br />VI. Tank Info <br />Capacity in <br />Total <br /># of <br />Manufacturer <br />Gallons <br />Gallons <br />Units <br />New Tanks <br />Existing Tanks <br />o <br />2 <br />U <br />Septic or Holding Tank <br />750 <br />1 <br />750 <br />1 <br />Wieser X <br />Dosing Chamber <br />VII. Responsibility Statement- 1, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. <br />Plumber's Name (Print) <br />Plumber's SignatMP/MPRs <br />Number <br />Business Phone Number <br />Rick Brown <br />231251 <br />419-0739 <br />Plumber's Address (Street, City, State, Zip Code) <br />PO Box 637 Spooner WI 54801 <br />VIII. Coun /De artment Use Only <br />Approved <br />El Disapproved <br />Permit Fee <br />Date Issued <br />Issuing Agent Signat e <br />$ <br />7`s <br />El Owner Given Reason for Denial <br />J <br />IX. Conditions of ApprovaUReasons for Disapproval <br />A r9,1PR Jut V[U <br />E ('";`E � V E <br />Attach to complete plans for the system and submit to the County only on paper not less than 8 l/ hes in size <br />117 JUL 17 2018 <br />SBD -6398 (R0313) BURNETT COUNTY <br />[UJ <br />ZONING <br />