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,: '''-174:•';,, County <br /> 4 <br /> ``;'- Safety and Buildings Division <br /> 1400 E Washington Ave �-1/~N C__ <br /> • � i <br /> 9 Sanitary Permit Number(to be filled in by Co.) <br /> f. :,.,% P.O.Box 7162 p <br /> ;', ........4',/ Madison,WI 53707-7162 ��'a�' 3`Q <br /> State <br /> Sanitary Permit Application Transaction Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit 620 1 /3 <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. q I7.2 6/-,1,,, <br /> , <br /> 3 ^,1 le <br /> rr <br /> u. Application Information-Please Print All Information <br /> �C �, <br /> Property Owner's Name �y Parcel# 07 (33,z o2 y/I4 r3 <br /> Li, ,S <br /> -5</SRrw F/ 'eG er /v ev) // /3 0,17 0/g6.›0 e.) <br /> Property Owner's Mailing Addrat <br /> /' / /� Property Location d P55 <br /> 8 <br /> 02 a gf 6/ 'go to f' r1�AIL./ /1 CJ Govt.Lot <br /> City,State Zip Code Phone Number /, %a, Section ,75-- <br /> ��J LI//; . A S 6-0 61, (circle one <br /> ;h. A ype of IStuading(check all that apply) Lot# T / / N; R/6 E o W� <br /> 2 Family Dwelling-Number of Bedrooms - t Subdivision Name <br /> Block# '/ ✓ _.Ay <br /> [i P ublic/Commercial-Describe Use *------- <br /> ❑ City of <br /> 0-1 -------- CSM Number 0 Village of <br /> State Owned-Describe Use <br /> ____ ,-Town of .5 ''v/5 5 <br /> f[l II.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' ❑New Systemr i2eplacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> I � <br /> i III <br /> B. I ❑ Permit Renewal 0 Permit Revision ❑ Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> j + Before Expiration Owner <br /> W.Type of]POWTS System/Component/Device: (Check all that apply) <br /> Nlon-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑MOund<24 in.of suitable soil <br /> 1 Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> 1 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 /> 5- 7 6y3 6.3-----e.) ?q, z <br /> VII.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units - o'b •o <br /> New Tanks Existing Tanks `•-• a L <br /> a. U co . Do 4, a a, <br /> Septic or Holdhf nk- tee9QO ,42 / /Po rce e.-5 c 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 j l / 227691 715-349-7286 <br /> !/V G�c'Y-� <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 <br /> Viii.County/Department Use Only <br /> i/;Approved 1 ❑Disapproved Permit Fee Dat Issu I n Agent Signa j QO / 3 �0 <br /> ❑Owner Given Reason forDenialIIX.Conditions off Approval/Reasons for Disaproveran cld sf be 590 ' te ml! I OI- &VM.'pra fkidAI'K 13 2Attach to complete plans fr the system and submit to the County only on paper not less than 8 1/2 x 11 inches in size <br /> SBD-6398(Rfl313) Burnett Coun <br /> Land Services Department <br /> 0011 Ifo 1,3 5°° <br />