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s .. County <br /> 10 <br /> Safety and Buildings Division <br /> 1400 E Washington Ave Sanitary Permit Number(to be filled inb/yeC.,o.) <br /> ` <br /> P P.O.Box7162 �fl� l-t,Z lob <br /> Madison,WI 53707-7162 <br /> 19 <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 Services. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s.15.04 1 m,Slats. 9 6�d �f}^q/� L K, lei <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# 0 7 03.Z <br /> h L �� ko �, <br /> w� � ���oQo a�si <br /> Property Owner's Mailing Address Property Location <br /> hVftdC e, Govt.Lot <br /> City,State Zip Code Phone Number 1A ��-A Section <br /> p.� C/jQ lr'e W rS'l 7o is S3/ 7a y2 circle one) <br /> II.Type of Building(check all that apply) Lot# T��N; R �� E ot© <br /> or 2 Family Dwelling-Number of Bedrooms _5 Subdivision Name <br /> _ Block# <br /> ❑Public/Commercial-Describe Use ❑City of --� <br /> ❑State Owned-Describe Use <br /> --- CSM Number ❑ Village of <br /> 0-Town ofw/SS <br /> 91.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> ❑New System Peplacement 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 <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> KNon-Pressurized In-Ground ❑ Pressurized In- round ❑ At-Grade El Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> El Holding Tank El Other Dispersal Component(ex ain) ❑Pretreatment Device(explain) <br /> V.Dis ersaYTreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> , 7 6 y f 7 <br /> VI.Wank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o <br /> New Tanks Existing Tanks o d D ro <br /> a U n y 2 i2 C7 G4 <br /> Septic or H"!!MiL�Fank <br /> Dosing Chamber ` 4— QO <br /> VII.Responsibility Statement- 1,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 J715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 <br /> VVIIII.Colin /De artment Use Only <br /> tt�t Approved El Disapproved Permit Fee Date Issued Isswng A ent I- <br /> 1A $ -y <br /> ❑ Owner Given Reason for Denial 3-2 5'_ v /7 <br /> I%.Conditions of Approval/Reasons for Disapproval <br /> PPROVFD N MAY IUJ <br /> 2 8 2019 <br /> BURNETT COUNTY <br /> Attach to complete plans for a system and submit to the County my on pa not less than 11 1/2 x 11 inches in size <br /> SBD-6398(R0313) ,4 <br /> J/ <br />