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,5;y,•,er, r':f, County <br /> Safety and Buildings Division /eirs/14 <br /> r;0 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> `t , i"1! P.O. Box 7162 "�,N ./Ilk <br /> "" Madison,WI 53707-7162 <br /> _ti. CSI"-w l31 <br /> qF%v�<:1.11,:�' / <br /> State Transaction NumberSauna. Permit Application <br /> (0?.8303 <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(different than mailing address) <br /> the Department of Safety and Professional Services. Personal information you provide may be used for secondary 70,"/ 7 <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. <br /> E. Application Information-Please Print All Information L^ Q <br /> Property Owner's Name ! Parcel i-()7 p,2 n -2 44, 76 <br /> �A..1 _ i ', J1 ? C/ ©©os `eve, <br /> Property Owner's Mailing Ad�ress Property Location � <br /> '��� <br /> 7 035-- 1yx ' Govt Lot <br /> City,State r �f�`j� Zip Code Phone Phone Number <br /> G� '7,4 g A)6-,/a � �, 019 <br /> t ei2 J iP'( Lo". Y /./ /�'' 77O%0 3 / f �.1 /<(circ E olne <br /> T 7O N; R / Ee o ail/ <br /> II.Type of Building(check all that apply) Lot# <br /> >41 or 2 Family Dwelling-Number of Bedrooms <br /> —, Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> u State Owned-Describe Use �� CSM Number ❑Village of / <br /> Town of OAr K bi-NCf <br /> DI.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. I ❑ New System X Replacement System ❑Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> I <br /> I <br /> B. 1 ❑Permit Renewal ❑ Permit Revision ElChange of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> { Before Expiration Owner <br /> iIII.Type of POWTS System/Component/Device: (Check all that apply) <br /> /ArNon-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade 0 Mound>24 in.of suitable soil 0 Mound<24 in.of suitable soil <br /> i 1 Holding Tank 0 Other Dispersal Component(explain) (explain) <br /> ❑Pretreatment Device <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 /> /5-0 , 7 /S -mss u• 73_ <br /> VII.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units L o 0 <br /> 0Ncw Tanks Existing Tanks 4 L o cn <br /> C1-.4 U m ti o7 w C7 a, <br /> I <br /> Septic or 1.4;ddi,+g-Ta1LL 1490 Ll Meo ! /ll o e4.)e 5 4 C' <br /> I <br /> Dosing Chamber <br /> VII.Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's SignatureMP/MPRS Number Business Phone Number <br /> WADE RUFSHOLM <br /> ell <br /> l i _ 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 <br /> VIII.County/Departnsent Use Only <br /> pproved 0 Disapproved Permit Fee D7sued ped gent Signature / <br /> 1 ❑Owner Given Reason for Denial $ 515. 00 � ,4 <br /> IIs:.Conditions of Approval/Reasons for Disapproval <br /> Dcpbiklot wtiAbr be, Sept Echo l euke I well _ .I , �i2R' g'� <br /> 3 4 SeptVAINDA bauget 1 darsroat a µcpaseuefs rertheed?. <br /> t'Tam Nk *iusl 4[ writ n Se acedidtO fOK. tiECEOVED <br /> P Attach to complete plans For the system and submit to the County only on paper not less than 8'R tches.1 172020 <br /> SBD-6398(80313) - <br /> Burnett County <br /> Land Services Department <br />