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county <br /> Safety and Buildings Division <br /> 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> P.O.Box7162 jAN_I`t`33 6 �q g7� <br /> Madison,WI 53707-7162 <br /> -25 <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. �yO _7'. <br /> 1. A Reation Information—Please Print All Information 015 dJ <br /> Property Owner's Name Parcel# O'? <br /> Property Owner's Mailing Address l Property Location <br /> 7l 3A Govt.Lot <br /> City,State Zip Code Phone Number A/14J /<, Section /„5— <br /> $yS 2 7� 7? /�3 (circle one <br /> / _ <br /> 11.7Cype of BIIaIlding(check all that apply) -^� Lot# <br /> T� N; R�6/ E o 4&' <br /> �or 2 Family Dwelling—Number of Bedrooms oL Subdivision Name <br /> Block# — <br /> ❑Public/Commercial—Describe Use <br /> ❑ City of <br /> ❑State Owned—Describe Use CSM Number ❑ Village of <br /> Town of /J!P�c�/�o�✓ <br /> 111.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> New System ❑ Replacement 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 /> 1V.Type of POWTS S stem/Coln onent[Device: Check all that a I <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.Dis ersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Disper I Area Proposed(sf) System Elevation <br /> o a <br /> Vff.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units J, o to <br /> New Tanks Existing Tanks y c Y L m <br /> C <br /> a.U in � � <br /> Septic or 11QWi T>) <br /> Dosing Chamber 5-0 _1 <br /> VIIII.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 / ? /J 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 <br /> V111.Coun /1De artment Use Only <br /> Approved ❑ Disapproved Permit Fee Date Issued Issuing A ent Stgna e <br /> ❑ Owner Given Reason for Denial <br /> EX.Conditions of Approval/Reasons for Disapproval 37 �. <br /> APPROVEU <br /> D <br /> ., <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 inc i in <br /> AM 2 2 1019 <br /> SBD-6398(R0313) <br /> Burnett County <br /> Land Services Department <br />