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y AR7M1ll:;:, County <br /> Safety and Buildings Division -,A e <br /> nas 1400 E Washington Ave <br /> 9 Sanitary Permit Number(to be filled in by Co.) <br /> P.O. Box 7162 gw- <br /> Madison,WI 53707-7162 [ <br /> —L <br /> I 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 Co2_04a.5 <br /> is required prior to obtaining a sanitary permit. Note:Application forms for state-owned POWTS are subnutted 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 PrivacyLaw,s.15.04 1 m,Stats. <br /> R. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# 0/ OCR G2 1717 <br /> / <br /> Property Owner's Mailing Address Property Location/"e- <br /> y Govt.Lot <br /> City,State Zip Code Phone Number y, yq Section <br /> (�' C/ 7 2 t/ <br /> 5 / 7,2 �� J C/ 1JJ.J 7 T N. R_47 <br /> 11.Type of Building(check all that apply) Lot# <br /> or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use - �.i <br /> �—'-' ❑ City of <br /> ❑State Owned-Describe Use -� CSM Number ❑ Village of <br /> ' '?_Town of�///�/7>/4_1 1-5 <br /> 111.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> ❑New System eplacement System ❑ Tteatment/Hotding Tank Replacement Only El 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 a ➢ <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/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> ysa -7 dy.3 6y� �, /I <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units J, o <br /> New Tanks Existing Tanks o v � <br /> OE U in rn w C7 G, <br /> Septic or liaLdii1 ink <br /> Dosing Chamber <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 Si ature MP/MPRS Number T Business Phone Number <br /> WADE RUFSHOLM /') 227691 715-349-7286 <br /> oe <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 <br /> VIIIIII.Coun /U9e ariment Use Only <br /> M�Approvcd ❑Disapproved Permit Fee Daate Iiuedd AgentSi tore4 <br /> Owner Given Reason for Denial $ J ' �• O� <br /> IX.Conditions of Approval/Reasons for Disapproval ") <br /> s�g.� , Neva oln 1�,�.�s-� b� �.�, C CD CE 0 M 1E <br /> APPROVID ess <br /> DIn <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 thi si <br /> SBD-6398(R0313) <br /> Burnett County <br /> Land Services Department <br />