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County„ 7 <br /> Safety and Buildings Division ..,•06W�^� � <br /> 0 s 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> PS K P.O.Box7162 SAN--19.252. <br /> Madison,WI 53707-7162 <br /> Sanitary Permit Application State Transaction Number ,Q <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit &°20 �" <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 LI 0j r j Ji '7c <br /> purposes in accordance with the Privacy Law.s.15.(14(1 Xm),Stats. % �/°'' <br /> I. Application Information—Please Print All Information <br /> Property Owner's Name. Parcel# ® 'j C t Y. „ (5'/„c-L'' `/ <br /> C ,=1-ro L j, c r A , 0 S c o p 25`0o 0 <br /> Property Owner's Mailing Address t PropertyLocation /3L <br /> 0 337 <br /> f� 92�i <br /> 02 l h 41ll ( /tie..('' IJ 1 t/" Govt.Lot <br /> City,State Zip Code Phone Number IA, 17/ <br /> {( 7 , /., Section <br /> ©A K GrO Ve. M ) ,`j3°S 3 T . 1 N: R / c <br /> E <br /> II.Type of Building(check all that apply) Lot# <br /> �l or 2 Family Dwelling—Number of Bedrooms / Subdivision Name <br /> �_ Block# <br /> ❑Public/Commercial—Describe Use <br /> ❑ City of <br /> CSM Number 0 Village of <br /> ❑State Owned—Describe Use y 1--.6---re, <br /> ,, / f <br /> V � /f / -.3 Town of /T'7'et 1,��-ite._, <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable)a <br /> A. 0 New System CXRe lacement System y p y 0 Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal 0 Permit Revision 0 Change of Plumber 0 Permit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> ion-Pressurized In-Ground 0 Pressurized In-Ground 0 At-Grade 0 Mound>24 in.of suitable soil 0 Mound<24 in.of suitable soil <br /> ❑ Holding Tank 0 Other Dispersal Component(explain) 0 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 /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units u o <br /> New Tanks Existing Tanks v g u 2 3 1 i <br /> C.: U in y r TL. v a <br /> Septic or Hetdntank /Gv/Sec} /G2Ck7 / /ry ''c t.f`( J Gel _7/ <br /> Dosing Chamber <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plu/m 's Si ure e MP/MPRs Number Business Phone Number <br /> WADE RUFSHOLM �L . 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 <br /> VIII.County/Department Use Only <br /> Approved 0 Disapproved Permit Fee Date I ued I Agent Signature <br /> ❑Owner Given Reason for Denial S 515. 00 II �7/lag <br /> IX.Conditions of Approval/Reasons for Disapproval , Q <br /> w�c5,aft�rec ot�.s, or' wt.eeG4ca4in►ts -h1 i <br /> t7(.trat.iHfitlGt wt -►C iscrhk Y. will t+t�u'it. a- <br /> i1 UJb11APPROVED <br /> r <br /> r, cprc+ct� "t:'�' �i ► C L�;t. n , Ninv 14 2019 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 z t Tac #a in dze <br /> Burnett County <br /> SBD-6398(R0313) Land Services Department <br /> CL.*' (1 ia5' S3r7 C <br />