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:-:;6,,,,h'66;':,;,, County <br /> Safety and Buildings Division eil'Iv e--7174-�;; 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> `_\r;s,� 5I P.O.Box 7162 s><ltl(–�/ <br /> Madison,WI 53707-7162 —59 <br /> Sanitary Permit Application State Tra//ns��actioznNumber <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit tYtsl� <br /> is required prior to obtaining a sanitary permit. Note:Application forms for state-owned POWTS are submitted to Project Address(if different than.mailin address) <br /> the Department of Safety and Professional Services. Personal information you provide may be used for secondary 't[0501 n <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. / <br /> E. Application Information-Please Print All Information ,, 7 71 -�277,,,r/,OSa2? Ay <br /> Property Owner's Name Parcel# c 7 a/ <br /> 7)) /Ke GJe �SeA r; PoS" /Viad <br /> Property Owner's'sMailingaiAddressk-,,,,,' <br /> ^ Property Location <br /> /' 3 / Cj I� f/l�<' i J/4 Ary 14 Govt.Lot <br /> City,State /Zip Code Phone Number <br /> i /<, /<, Section �.� <br /> �/�} / M/0 Y�V r bele one <br /> " e 1 e T 4 .' N; R %) Eo <br /> III.Type of Building(check all that apply) Lot# <br /> or 2 Family Dwelling-Number of Bedroo <br /> 3 Subdivision Name <br /> Block# <br /> 0 Public/Commercial-Describe Use ❑City of <br /> State Owned-Describe Use CSM Number ❑ Village of <br /> ( 19. /6/. 2 `Town of J-11- -1-c <br /> 1111.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> ❑New System 'Replacement System 0 Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> B. I ❑ Permit Renewal ❑Permit Revision ❑ Change of Plumber <br /> j { Before Expiration Owner <br /> I <br /> IV, ..Type of POWTS Systenn/Co pereent/Device: (Check all that apply) <br /> Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> 0 Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil` •Application Rate(gpdsf) Dispeerrsal Area Required(sf) Dispersal Area Proposed(sf) System Elevation / <br /> 5e) / 6'/3 - C) ._.5..:, ✓ <br /> VII.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o 3 o <br /> Ncw Tanks Existing Tanks v o 0 o Ti .8 2 <br /> �1 /� 11 <br /> w U fn' . rn w o P, <br /> Septic or I3oidirtgT�ltl'' /D�J�) '� fee!1 / /O C�I 4)L�5 0 "7`� <br /> Dosing Chamber <br /> J <br /> VII.Responsibility Statement- I,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 RUFSHOLM227691 715-349-7286 <br /> �� <br /> /4-,.m <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 <br /> VOL.County/Department Use Only <br /> 4pproved 0 Disapproved Permit Fee Dat ssu • ent Signa <br /> ❑ Owner Given Reason for Denial 313r y/�/�30 <br /> IIIX,Conditio10 ns <br /> �ooff Approval/Reasons for Disapurroval /�_rI <br /> t. <br /> iepfk mac w4.44.0 Mows cod Ge1mp/h►M'f' 0444441- ;cher. [ © E Q V I it <br /> 4.Old wu4sz!' loc. d•0.44.de►iwc� pre' SPS. 383. D <br /> Atmch to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 1 itc n siM AI{Y 6 2020 <br /> t p <br /> 1U) <br /> SBD-6398(R0313) <br /> Burnettounty <br /> Land Services Department <br />