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;"i�aF_rVI,i:: County <br /> Safety and Buildings Division y/jtV� <br /> Us? ', 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> ' 'j":; P.O. Box7162 5'ANi-ao - ii/3 <br /> Madison,WI 53707-7162 <br /> -Fr.._ _ a tT-av -I ' ' <br /> Sanitary Permit Application State Transaction Number <br /> & aJD <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 di Brent than Inailin address) <br /> the Department of Safety and Professional Services. Personal information you provide may be used for secondary '77c 5 lw4`,0 <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. // /� q, <br /> L. Application Information-Please Print All Information •f 2 .;;7/)SQ''`L , ••7 <br /> Property Owner's Name ` <br /> Parcel# p 7 Q/ 9' <br /> ..2 D /-6 075— <br /> GAr y G-e.;a/5 5 e)5— 0 0,2 <br /> Property Own s Mailing Address Property Location pe__/ <br /> F/Z5 a©©(jrO c) 7 Govt Lot 3.---- <br /> City,State Zip Code ` Phone Number /, /, Section 7 <br /> i ,-3S e9 <br /> . S_3 7// �` _(,.circle one <br /> IL Type of Building(check all that apply) Lot# T �f n N; R /_. E <br /> r 2 Family Dwelling-Number of Bedrooms <br /> Subdivision Name <br /> �— Block# <br /> Public/Commercial-Describe Use ,�, ❑ City of <br /> ❑State Owned-Describe Use <br /> CSM Number 0 Village of r.___—.. <br /> //F Q V (Town of \ TnC/‹.S C <br /> Illi.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. i ❑New System Replacement System ❑Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> B. 1 0 Permit Renewal ❑Permit Revision ❑Change of Plumber 0 Permit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> 1 Before Expiration Owner <br /> 1v7.Type of POWTS System/Component/Device: (Check all that apply) <br /> � <br /> L7on-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.IIDispersall/II'reatment Aires Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> r_ 30a ' 7 (� 93—e) 2 <br /> Vii.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units „ o <br /> alNew Tanks Existing Tanks c E L <br /> a, U in � to <br /> w v 0., <br /> 1 <br /> Septic or / e e , laud / /v e, r4c)cf 5c_© i----- <br /> Dosing <br /> ---Dosing Chamber <br /> Vali.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 /�,/�• _O / 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) (/(/ �e`4-�/ <br /> PO BOX 514,SIREN,WI 54872 <br /> VIM.County/Department Use Only <br /> Approved ❑Disapproved Permit Fee DDate su n gent 51gn e;7446/14.04, <br /> epe. ` <br /> 0 Owner Given Reason for Denial 1;5' oa 4- `/202a <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> $ /WO hvt %tu k f b �c. amudo.� ed per SPS. XS. C(l l5�2(0 *4-.25- <br /> 34 <br /> 4- _ <br /> 34 ,,t�iteicR F � ltAkl, [� © Q W <br /> D <br /> EO <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 in x 11 i'eh I size j U L 1 5 2020 <br /> SBD-6398(R0313) <br /> Burnett County <br /> Land Services Department <br />