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County <br /> Safety and Buildings Division x- 4/I-lo e-171 <br /> 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> + $p s' )w.} P.O. Box 7162 <br /> 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 <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 ye!/Czl L� <br /> purposes in accordance with the Privacy Law,s.15.04 I m,Stats. <br /> I. Application Information-Please Print All Information <br /> Property Owner's Nameyy Parcel#0 7 0 3 1 a Vo f 7 0?S <br /> / � J— ooc�, <br /> Property Owner's Mailing Addre s Property Location 9 pZJ� <br /> Govt.Lot ^� <br /> City,State Zip Code Phone Number y4, %4, Section pc JJ <br /> ,�, circle o <br /> II.Type of Building(check all that apply) S5 oZ Lot# T N; R E <br /> lQ1 1 or 2 Family Dwelling-Number of Bedrooms Q,OU��c�� Subdivision ame <br /> Block# J G,/�' S 44 G41C <br /> ❑Public/Commercial—Describe Use ❑ City of .� <br /> CSM Number El Village of r� <br /> El State Owned—Describe Use Town of 64V,.0 g2 <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' ❑New System <br /> y El Replacement System Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. El Permit Renewal Permit Revision El Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS S stem/Com onent/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(gpdsl) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> �Od <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units r, U c <br /> Ncw Tanks Existing Tanks y o 9 R m <br /> a U n � w C7 p, <br /> Septic or an loe�, oC/� /e*o ��,/�Lei' i C" <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) Plumber's Signature MP/MPRS Number Business Phone Number <br /> WADE RUFSHOLM / �� 227691 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 /> Approved El Disapproved Permit Feed Date Issued ,1q Issuing Agent Signature <br /> ElOwner Given Reason for Denial $ �J ' 7-IR r// <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> � E � codIE <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 size U, <br /> JUL 1 2019 <br /> SBD-6398(R0313) <br /> Burnett County <br /> Land Services Department <br />