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,:.;.i.ol vi:::.., County <br /> °.,. Safety and Buildings Division A4>-pit)e <br /> 11- <br /> 1400 E Washington Ave <br /> � 9 Sanitary Permit Number(to be filled in by Co.) <br /> �.�.1,,g, I''I P.O.Box 7162 5AN)—.20 <br /> _�� <br /> Madison,WI 53707-7162 C5-1---20 <br /> State Transaction Number <br /> Sanitary Pei irii t Application (0�3�0er <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit <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 /> II. Application Information-Please Print Ali Information <br /> Property Owner's Name Parcel#0 7 a ,2 '/p /*'JC <br /> \ r <br /> i <br /> 1), hit) /n//JoyN� sv.5-r,06 ©/Yon ii.MAI) <br /> Property Owner's Mailing AcTress Property Location/ e / <br /> /�l NJ p <br /> �/ Q o /J/�L�6(4rit /1 ci Govt.Lot <br /> City,State Zip Code Phone Number 5 C <br /> /4, <, Section 3 <br /> S pc�i v f-toe rn� s 7656' / 655--re, 7 T �P N' R / (circle ones/ <br /> II. .l ype of Building(check all that apply) Lot# <br /> y.,or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> 3 <br /> Block# <br /> ❑Public/Commercial-Describe Use -- ❑ City of <br /> — CSM Number ❑Village of <br /> 0 State Owned-Describe Use <br /> v own of -SG0 <br /> M.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' ❑New System Xi Replacement System ❑Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> I ! <br /> ay. List Previous Permit Number and Date Issued <br /> 0 Permit Renewal ❑Permit Revision ❑ Change of Plumber 0 Permit Transfer to New <br /> j I Before Expiration Owner <br /> I.V.TI ype of POWTS Systeun/Co ponent/Device: (Check all that appy) <br /> 5eNon-Pressurized In-Ground ❑ Pressurized In-Ground 0 At-Grade 0 Mound>24 in.of suitable soil 0 Mound<24 in.of suitable soil <br /> 0 Holding Tank 0 Other Dispersal Component(explain) ❑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 /> j ySo . 7 & Y3 ‘5-6) 7L2 • <br /> f W.Tank Info Capacity in Total #of Manufacturer <br /> :: <br /> Gallons Gallons Units .no 7., 0 <br /> New Tanks Existing Tanks 0 a Y <br /> ISeptic or fkldAT IVItc' 1 AN,(,0 /i7"0 / ,1' -.s c <br /> i Dosing Chamber <br /> VEL.Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> j Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> WADE RUFSIIOLNt �1t _/ fi% � 227691 715-349-7286 <br /> I ^SCE y_....-. <br /> IPlumber's Address(Street,City,State,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 <br /> VIII County/Departnnent Use Only / <br /> 1 pproved 0 Disapproved <br /> Permit Fee Date ssue ng gent Signa e <br /> liti <br /> ❑Owner Given Reason for Denial $ 5 . �� ��b �� <br /> IX.Conditions of Approval/Reasons for Disapproval ` 3� 8�� <br /> is l&takiitc. w As-t t� Wei C� C� C U M C <br /> ! <br /> * 0Ia fbwr5 w�,+�csf be remwve t. pct SPS. add t <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 inches in i APR Z 9 2020 J <br /> SBD-6398(R0313) Burnett County <br /> Land Services Department <br />