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PtL,LR711!`j County ��i <br /> Safety and Buildings Division �7! <br /> 1400 E Washington Ave 9 Sanitary Permit Number(to be filled in by Co.) <br /> P � P.O.Box7162 ! ' <br /> �\ S Madison,WI 53707-7162 � <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 & /S`r <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 addre ) <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,Stats. <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name , Parcel#©`7 o-35/ A 37/8Z2/ 5-' <br /> f I/ 10f—L 0 - OCC o ;� Oct * <br /> Property Owner's Mailing Address Property Location/J c�J <br /> _ <br /> .7 .35 / /n G-� �� u/U! � Govt.Lot _3'f'� <br /> ity,State Zip Code Phone Number /� <br /> /s, Section 1 <br /> l5 //I/V. J y� 6ia-963 S✓�36— circle one <br /> II.Type of Building(check all that apply) Lot# T 3,7 N; R E o W <br /> Y•I or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use - <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number El Village of(� y <br /> V3 / J o Town of ��C� <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑New System Replacement System g p y g y (explain) <br /> ❑ Treatment/Holdin Tank Replacement Only El Modification to Existing System <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 /> ❑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/Treat ent 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 E d <br /> New Tanks Existing Tanks o y <br /> n U <br /> Holding Tank /,D C� /. 1 �s•� r^ <br /> Dosing Chamber L.(J <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 L f I _. 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) %lam <br /> PO BOX 514,SIREN,WI 54872 <br /> VIII.Count /De artment Use Only <br /> Approved ❑Disapproved Permit Fee DDate slue I gent Signature <br /> ❑ Owner Given Reason for Denial $ 3"f �•00 v <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> won v�"t" GYV6 AWf n1A4,+- aquin Ket-fs Co irl `6_3-2 5 <br /> �n 3$3. y3C$XJ) nn A � L9 d dLF. <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 112 x 11-nefiminsize <br /> SBD-6398(R0313) AUG 12 2019 <br /> Burnett County <br /> Land Services Department <br />