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Count r <br /> Safety and Buildings Division �- <br /> 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> P.O.Box 7162 <br /> Madison,W 153707-7162 <br /> Sanitary 1C ennit Application State Transaction Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of thus form to the appropriate governmental unit (", 04,3 5 <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 /> 1. Application Information—]Please Priest All IInformation <br /> Property Owner's Name Parcel# 6 7 O 1/ a?. 317 V <br /> e nJ S O y ooD <br /> Property <br /> )Owner's Mailing Address t Property Location +� <br /> 1/t� o �f f�C�r i / /) ` Govt.Lot <br /> City,State ZipCode Phone Number -_ , <br /> �� /<, 3 4E' /a, Section pZ� <br /> i & t U�� �t• 5 7 / ,�5—if �v�/O (circle one <br /> 11.Type of Building(c eck all that apply) Lot# T .3 N; R E W <br /> Al or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> i <br /> Block# <br /> ❑Public/Commercial-Describe Use ^- ❑ City of `-- <br /> ❑State Owned-Describe Use CSM Number ❑ Village of '�� ip <br /> Town of Gt✓ "91/"r/► <br /> r-5 14AIIIJ <br /> 111.Type of Permit: (Check only one box online A. Complete line B if applicable) <br /> A. ❑New System [Fteplacement System g p y g Y (explain) <br /> ❑TreatmenUHoldin Tank Replacement Onl they Modification to E stin System <br /> QX a�jte� e,� wlot� <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of PlumbeT09w <br /> Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration ner <br /> TIV.Type of POWTS System/Component/Device: Check all that apply) <br /> ❑Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade -Mound 124 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> 10 Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dis ersaYrreatlnent Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> V.'Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o <br /> New Tanks Existing Tanks o .2o A CZ <br /> a U n va w C7 n <br /> Septic or n ank <br /> Dosing Chamber ��lS <br /> VIIII.Responsibility Statement- 11,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature n MP/MPRS Number Business Phone Number <br /> Z WADE RUFSHOLM f)�j 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) ��i• <br /> PO BOX 514,SIREN,WI 54872 <br /> V11 1.Count /®e artment Use Only <br /> proved ❑Disapproved Permit Fee <br /> $ Date ssue Agent 'gnature <br /> El Owner Given Reason for Denial 3T• •L6M <br /> Conditions of Approval/Reasons for IDisapprova➢ <br /> M All %,Fe a v -to be wt; <br /> FnfT 3 0 201 <br /> lu 10 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1 x 11 in hes in siu <br /> Burnett County <br /> SBD-6398(R0313) Land Services Department j <br /> �..r * t560 _tS_76° <br />