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. r;,u 4i',;:r, County <br /> `'• Safety and Buildings Division ,�c�r/-� <br /> '> t 't• 1400 E Washington Ave <br /> • '���3 9 Sanitary Permit Number(to be filled in by Co.) <br /> ) ' P.O.Box 7162 ^N - _ <br /> Madison,WI 53707-7162 i� �i] <br /> Sanitary Permit Appucatio StateTransactionN�um2bcr <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit G�3 ^J <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. 6A MO <br /> ( I. Application Information-Please Print All Information <br /> Property Owner's Name I Parcel#C)'7 0/...2y0 /6 /S <br /> /1 e it) o <br /> s0 � m ©N5 oA,) 5-is- 7.5'"$4 0 5/6 oe o_ <br /> ( Property Owner's Mailing Address r Property Location ti Bao` <br /> ! <br /> ? 7 03 .3 "vi /e__ RAJ Govt.Lot <br /> City,State Zip Code Phone Number /s <br /> spfild �) /<, /n, Section <br /> i q r�j 01— 5 y b!j y o . circlEe on <br /> T yN; R / 0(5 <br /> U.Type of Building(check all that apply) Lot# <br /> ' .or 2 Family Dwelling-Number of Bedrooms 3 0 '7 Subdivision Name <br /> Block# /rQ 4 f s,r/y5 /1111` V <br /> .Public/Commercial-Describe Use <br /> ❑City of <br /> - '�— CSM Number ❑Village of �'— <br /> �_.State Owned-Describe Use <br /> Town of '0/9 C k- 5 0 ni <br /> ,0[f.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A_ 0 New System KReplacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. 0 Permit Renewal ❑Permit Revision ❑ Change of Plumber 0 Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> PI.Type of POWTS Systema/Component/Device: (Check all that apply) <br /> X't Ton-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> iJ Holding Tank 0 Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Plow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> y5 o '7 ey3 ‘5 c) 98 ® 6 <br /> Vil.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o'2 0 <br /> New Tanks ExistingTanks w " U v e• i 2 <br /> d o � 1 2LI 41 <br /> a U cn y rn w a a <br /> Septic or Nolt.liug T-exrir Doe .— I rr <br /> Dosing Chamber / D v 6 / !— 6eri F? L, 111 (( �` <br /> "III,Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumb is Signature MP/MPRS Number Business Phone Number <br /> WADE RUFSHOLM 227691 715-349-7286 <br /> ,L C,ce <br /> Plumber's Address(Sheet,City,State,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 <br /> VIII.County/Department Use Only <br /> Permit Fee Date ssu I ent Signa e / / / <br /> p APProved I ❑Disapproved $ 1 �/� <br /> i 1 ❑Owner Given Reason for Denial SS• it t `R/�/�A�. / <br /> I DC Conditions of Approval/Reasons for Disapproval C to I-. lat. $.2125,06 <br /> �d lire ►��ek� wvusf Itia�e. 2 orF eo�e% . d <br /> 0 pfa.6n.�1JJ 04(A.3# 6 4+ F✓oii IA:64,. . D i <br /> --- <br /> Attach to complete plans ffarr the system and submit to the County only on paper noPDeesss-than 8 1127 in t[6 in <br /> MAY 1 1 2020 di <br /> SBD-6398(R0313) <br /> Burnett County <br /> Land Services Department <br />