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} ._ ,itr',; .., County <br /> :, Safety and Buildings Division /24-1/`Ai ' <br /> '> ?n 'K' 1400 E Washington Ave <br /> -�: , ., �,�E 'IT'�i g Sanitary Permit Number(to be filled in by Co.) <br /> ' �. P.O.Box 7162 �'r�.t ... 37 <br /> �._.... <br /> .$ Madison,WI 53707-7162 <br /> '>>•,•:u ,, ,''.' 6N--20 12z <br /> State Transaction Number <br /> Sanitary Permit Application � �s� <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.I5.04(1)(m),Stats. Gy y ` 0 <br /> L Application Information-Please Print All Information l// 71-/— <br /> Property Owner's Name Parcel# 06 Si cl:2 900 c) <br /> Ke- <br /> (/M 7,1epKe. 07 o2' .• '4' %4/ a4/5c <br /> Property Owner's Mailing Address Property Location ,p e- / #''. 46 <br /> )1/3 Of}•icV/E-i :1 Z-4J,- 4, Govt.Lot 1// / <br /> City,State Zip Code Phone Number � y, <br /> y, Section Y <br /> /�/e 1.7r tie 4),l). .- 5-3`x' ? l7 <br /> ? 57 77-3�� (circle one) <br /> { T VO N; R i5/ Eotu <br /> IL Type of Building(check all that apply) Lot# <br /> or 2 Family Dwelling-Number of Bedrooms OZ Subdivision Name <br /> Block# .----- <br /> ---- <br /> 0 <br /> "`.r3❑Public/Commercial-Describe Use �- ❑ City of <br /> ' 0 State Owned-Describe Use CSM Number 0 Village of <br /> } -`- p Town of 5c=-o7cr <br /> lilit.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> 4. 0 <br /> New System Replacement System ❑ Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> B. 0 Permit Renewal ❑Permit Revision ❑ Change of Plumber El Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> i I <br /> iIV.Type of POWTS System/Component/Device: (Check all that aptly) <br /> I g-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 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 /> 366 / 7 <br /> C �sJC <br /> 4-/-2.`7 1-5"---0 ' 7 <br /> V.I.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units .a o ,b, o <br /> I New Tanks Existing Tanks vc 0 U y <br /> w in CI) <br /> i 0 G., <br /> i <br /> Septic or Hel4iar-Panic ./ <br /> l c)()C� /vDe / fLtO/'GJ�-IC-C.) ! <br /> -- <br /> Dosing Chamber I 210 55,4) / ..=tel///%44,f` <br /> • <br /> VIII.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 RUFSHOLM j ad 1/ y ��.,..__. 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 /> pproved I ❑Disapproved Permit Fee Date ss suing gent Sign e <br /> JO .7- 4/21021) <br /> of 1 ❑ Owner Given Reason for Denial $3 <br /> I5 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> kgisims s sfou 40 Mc aiviudeoctsd per SK 3n. ,1 153(0 <br /> *ma be ornrK Stud. D I' <br /> Attach to comp plans for the system and submit to the County only on paper not less than 8 1/2 x 11 ■; r size <br /> JUL - 7 2020 <br /> SBD-6398(R0313) <br /> Burnett County <br /> Land Services Department <br />