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,.•t ; rlir}tr. County <br /> Safety and Buildings Division q/'A)e.- <br /> '"^,' 1400 E Washington Ave <br /> 9 Sanitary(Permit Number(to be filled in by Co.) <br /> `,ti$p `'I P.O. Box 7162 SA'/v— — 14. <br /> .1.'PI.% Madison,WI 53707-7162 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit G2232 <br /> 41 <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. ' <A ! f'",,, <br /> I. Application Information-Please Print All Information JF�M� <br /> Property Owner's Name Parcel# 0 7 O ag 4/, 141 07 <br /> 49-re, #O`rs **4e L3-- 7b4 e o II•. <br /> Property Owner's MailingaiinAddress} /+/�n ' Property Location iq45- <br /> 3d/a ' /e/L) 1 ! !,4 -'e Govt.Lot <br /> City,State Zip Code Phone Number <br /> /or, lel) [[jje /<, /<r, Section <br /> �) V N -- - /$3e /�]' �^ /�^p 3'Jlcircle on <br /> G T � N; R � Eo W <br /> IL Type of Gilding(check all that apply) Lot# <br /> 1' I or 2 Family Dwelling-Number of Bedrooms 71/ - 7-6- Subdivision Name <br /> r <br /> ❑Public/Commercial-Describe Use V <br /> ✓ Block#' 5pri,f!.� Gre "�p V <br /> ❑ City of✓ -� <br /> 0 State Owned-Describe Usc <br /> f CSM Number 0 Village of <br /> KTown of ..-5-e-C77171- <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' 0 New System �Re lacement System Y p y 0 Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> B. 0 Permit Renewal 0 Permit Revision 0 Change of PlumberList Previous Permit Number and Date Issued <br /> 0 Permit Transfer to New <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> gNon-Pressurized In-Ground ❑ Pressurized In-Ground 0 At-Grade 0 Mound>24 in.of suitable soil 0 Mound<24 in.of suitable soil <br /> ❑ Holding Tank 0 Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> DesignFlo ( d) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Disper Area Pro osed(sf) System Elevation <br /> 43 <br /> Tank Info Capacity in Total #of Manufacturer GA° 476 <br /> Gallons Gallons Units a w 6 <br /> New Tanks Existing Tanks 45, 2 u u 72 a <br /> a. U fn rn w c7 a, <br /> Septic or Iialdiagk / y.�C5 a /A)6:,of I /O��� / � <br /> / ii— <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 Signature MP/MPRS Number Business Phone Number <br /> WADE RUFSHOLM / / 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> ` �j <br /> PO BOX 514,SIREN,WI 54872 <br /> VIII.County/Department Use Only <br /> Approved 0 Disapproved Permit Fee Date 7sluing A ent Sigma / <br /> 0.10 <br /> 0 Owner Given Reason for Denial i i _ <br /> IX.Conditionsoff Approval/Reasons for Disapproval / <br /> 4exrshvt brA,..Atid AI be abmelesictect per $Ps.V.i. DE © IIV <br /> G 1 <br /> v Dtatatad ktAust be tQ. 4,.N+ Poitie.e. 1 <br /> 4 t3 & Md.(ts of .Zit6 {or f.Z Aids re.'oed2. �y) r 0 2020 J <br /> Attach to complete plans for the system and submitfo the County only on paper not less than 8 1/2 x _in.1 in Si9k J!7 7 <br /> SBD-6398(R0313) Burnett County <br /> Land Services Department <br /> O<153/.2 .h.?. --' <br />