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County <br />Safety and Buildings Division�r <br />7t; P <br />1400 E Washington Ave <br />Sanitary Permit Number (to be filled in by Co.) <br />P.O. Box 7162 <br />Madison, WI 53707-7162 <br />�- <br />i-�5'--7 <br />Sanitary Permit Application <br />State Transaction Number <br />In accordance with SPS 383.21(2), Wis. Adm. Code, submission of thus form to the appropriate governmental unit <br />is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POINTS are submitted to <br />Project Address (if different than mailing address) <br />the Department of Safety and Professional Services. 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. Application Information - Please Print All Information <br />Property Owner's Name ! <br />Parcel # C-a 1 0 <br />Property Ownlks Mailing Address <br />Property Location -0 / S / <br />a7-PI <br />6� y �%/� I w <br />(9 <br />Govt. Lot <br />y, %,, Section <br />City, State <br />Zip Code <br />PhfoSne Number <br />/ ' 7 <br />ur (N <br />�O � <br />G' 3 zo Q7 <br />T i N, R (circEle oone <br />f—) <br />II. Type of B ding (check all that apply) <br />Lot # <br />-� <br />�1 or 2 Family Dwelling - Number of Bedrooms 1_^ <br />f 5L3 <br />Subdivision Name <br />,��,n;f � /',�� ��,d�C7 V, yR' <br />Block# <br />El Public/Commercial - Describe Use <br />-� <br />❑ City of <br />❑ State Owned -Describe Use <br />❑ Village of r <br />Number <br />-� <br />_S^Townof T,4C.k jc-m) <br />III. Type of Permit: (Check only one box on line A. Complete line B if applicable) <br />A. <br />❑ New System <br />eplacement System <br />❑ Treatment/Holding Tank Replacement Only <br />❑ 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 System/Component/Device: (Check all that apply) <br />Ion -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/Treat ent Area Information: y &,) 07 9 <br />Design Flow (gpd) <br />Design Soil Application Rate(gpdsf) <br />Dispersal Area Required (sf) <br />Dispersal Area Proposed (sf) <br />stem Elevation <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 />c <br />o <br />aUi <br />a. U <br />in <br />rn <br />w C7 <br />P, <br />Septic or+loWimg-Pank <br />_ <br />n <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 Signature <br />MP/MPRS Number <br />Business Phone Number <br />WADE RUFSHOLM�`J <br />�- <br />227691 <br />715-349-7286 <br />Plumber's Address (Street, City, State, Zip Code) <br />PO BOX 514, SIREN, WI 54872 <br />VIII. Count /De artment Use Only <br />A'Approved <br />❑ Disapproved <br />Permit Fee _ <br />Date Issued <br />Issui t SiAaKfft <br />$ <br />7-7��� <br />El Owner Given Reason for Denial <br />194 <br />IX. Conditions l/Reasons for Disapproval (j t>%J (� <br />DLJv L.c, <br />E � <br />kPPROVED D) <br />PJ�N 21 2019 <br />Attach to complete plans for thCsystend submit to only on paper not less than 8 1/2 hl in'Tin size 'SBD-6398 (R0313) ecfe <� t Burnett County <br />Land Services Department <br />