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count <br /> Safety and Buildings Division <br /> K. 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> u.�y P.O.Box 7162 <br /> Madison,WI 53707-7162 ►<<N <br /> Sanitary Peflt Application State Transaction Number <br /> in accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit &j`t l,4-4 <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,Stats. <br /> I. AppRication Information-]Please Print All Information <br /> Property Owner's Name Parcel# <br /> 0 7 0_3�4 .-2 yr, i 7.25/ <br /> Property Owner's Mailing Address Property Location <br /> a� 3 0 6 E �/�s/ � R Ae Govt.Lot <br /> City,State Zip Code Phone Number Y<, %,, Section oC 7 <br /> /4/l1 t/; ��- `J �O 3L7 2_,-�/ (circle one <br /> 11.Type of Buil ng(check all that apply) Lot# T �j�-`�2 N' R7 E o V��' <br /> V.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 <br /> CSM Number ❑Village of <br /> ✓/,/y? � / WFown of <br /> HE.Type of Permit: (Check only one box on line A. 'Complete line B if applicable) <br /> A, ❑New System P'Re lacement System y p y ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber List Previous Permit Number and Date Issued <br /> g El Transfer to New <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.HDis ersal/Treatruent Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> c <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o b <br /> New Tanks Existing Tanks y <br /> o � <br /> aU rn � wc7 w <br /> Septic or Pik 61) <br /> Dosing Chamber 6-0 <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 715-349-7286 <br /> Gi1J <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 <br /> ;IIIII.Count /➢De artment Use Only <br /> proved ❑Disapproved <br /> Permit Fee Date ssu Iss i g Age t Signatw <br /> p Q�� nn�� <br /> El Owner Given Reason for Denial $ J <br /> M.Conditions offroval/IIBeasons for Disapproval UIX <br /> APPROVED <br /> nn ,9 EIVEnni <br /> Attach to complete plans for the system and submit to the County only on paper not less than 81/2 x 1 siu <br /> SBD-6398(R0313) AUG 5 2019 <br /> Burnett County <br /> Land Services Department <br />