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Safety and Buildings Division ,�J�"/7/7`� <br /> 7 <br /> 1400E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> 1lle' '' i'' P.O. Box 7162 <br /> Madison,WI 53707-7162 <br /> State Transaction Number <br /> Sanitary Permit Applic.tion (,231g1 <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 Adc]re s if different than mailing address) <br /> the Department of Safety and Professional Services. Personal information you provide may be used for secondary y <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. G r, r'- 6,e.rt /)14-(3h <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# Q 7 er7"/ 3 %.S ("4/ <br /> ..5--- 0.6C,C)4 0,7 6000 <br /> Property Owner's Mailing Address Property Location /0c./ 0935 <br /> /00 / QAk )cc c L.A.) Govt.Lot V <br /> City,State Zip Code Phone N mber <br /> / / // _ l _ (� %<, /, Section <br /> ou.14_�,/v/u4 tri . ) .-5(�Co 0 l 7 ei, _,/ "?=-37/ 3� ..(circle one <br /> { T N; R (3 EorU> <br /> 11U.Type of Building(check all that apply) Lot# <br /> _ Subdivision Name <br /> pi( or 2 Family Dwelling-Number of Bedrooms <br /> Block# ^' <br /> ❑Public/Commercial-Describe Use ❑ City of - <br /> �� CSM Number ❑Village of <br /> ❑State Owned-Describe Usef `e //,�L <br /> 0 Town of ft)l! <br /> DLII.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' ❑New System Replacement System 0 Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ' ❑Change of Plumber ❑Permit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> Permit Renewal ❑Permit Revision <br /> Before Expiration Owner <br /> i I <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> 7-Non-Pressurized In-Ground 0 Pressurized In-Ground 0 At-Grade 0 Mound>24 in.of suitable soil 0 Mound<24 in.of suitable soil <br /> ❑ Holding Tank ❑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 Elevationle <br /> F� <br /> Sob l i ;✓. <br /> Qs 7,7, 3— ,�S— _ YC <br /> VL Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units .a al o b„ 0 <br /> P. �New Tanks Existing Tanks o i .2 .5 PT. <br /> a U n . so w C7 , <br /> Septic or maretii=ga ...-. ..." lt'av /co / N/crCAJ e,.S <br /> C-c <br /> Dosing Chamber <br /> VIII.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 ) /f es 227691 715-349-7286 <br /> (i•L/C.tCLa/ <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 <br /> vin.County/Department Use Only <br /> / proved ❑ Disapproved Permit Fee Dat Issu Fent Signator <br /> ),A.-- <br /> $315.Ob VAii.Z0,6 <br /> ❑ Owner Given Reason for Denial <br /> ' <br /> IX.Conolitions of Approval/Reasons for Disapproval <br /> $(4451 USt Qtto imott toiuporttvi,'+' wa i. 14- 1� X375 <br /> soLe twiRcitteot ram fed at f1'w C of sped'i N, © E o d <br /> D <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 1.11ch ih size, <br /> J U N 2 9 2020 <br /> SBD-6398(80313) <br /> Burnett County <br /> Land Services Department <br />