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;;iw.ctii::;:, County <br /> Safety and Buildings Division c/!-/t� <br /> -, 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> `-,N S <br /> r 1,--) <br /> P.O. Box 7162 /'1-I(i-2C) - t co 5 <br /> w ; Madison,WI 53707-7162 <br /> - .... , ,4.:.-',. <br /> CS7--20- l 4..5 <br /> Sanitary Permit Application State Transaction <br /> Numbcr <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit 692 R <br /> v 122 <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 3 5)0,2 <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. p <br /> II. Application Information-Please Print All Information /1✓4'/ 'akt) e_/'` <br /> Property Owner's Name Parcel# p'7 04;2 Z 4/0 /5-7/ <br /> Soh') Sig-7n m/er 5 /5 ( 0,71 loce) <br /> Property Owner's Mailing Address Property Location Ft 4932' <br /> riga y ` <br /> G I G�}Cf C7 ��� J !,i�u i 9/6--- Govt.Lot <br /> City,State J Zip Code Phone Number / y, /<, Section / <br /> 1 y» /5 /27/()' 5:5-Y0 7 Cj/ , Z.."- 7G ‘lj 7't leiN; <br /> one <br /> II . ype of Building(check all that apply) Lot# T V(9N; R / E ot� <br /> 1 or 2 Family Dwelling-Number of Bedrooms -5 5 2, Subdivision Name <br /> Block# R � <br /> Al/ '4".J Po O4,-) =fd 1 t' t i ` <br /> ❑Public/Commercial-Describe Use -- _- <br /> ❑City of <br /> ❑State Owned-Describe Use ✓ CSM Number 0 Village of l <br /> gTownof \TACFC5!JA ) <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> 0 New System ZReplacement System 0 Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> ' Before Expiration Owner <br /> IV.Type of POWTS System/Col ponent/Device: (Check all that apply) <br /> jNon-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) 0 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 /> 6/5-0 , 7 14/3 Z50 13" <br /> VII.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units A w o 0 <br /> New Tanks Existing Tanks 0 o y R 5 <br /> a. U in m co is C7 a, <br /> Septic or Holding aak /2,,c i-lex, Q 4. <br /> Dosing Chamber <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'sSignature 227691MP/MPRS Number Business Phone Number <br /> WADE RUFSHOLM // -,„„...-06.-..._... <br /> 227691 715-349-7286 <br /> AieteLC is �� <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 <br /> VIII.County/Department Use Only <br /> Approved ❑Disapproved Permit Fee Date I u elssutng nt Signature / <br /> 00:40 Owner Given Reason for Denial <br /> $ .00 f�.,720)0 _ / � _ <br /> IX.Conditions of Approval/Reasons for Disapproval ✓ t� 3. - '`" C�E EIy� E '— <br /> � tsh'hs Static. wvwsf I. a �Io►t�oito(tuaQr.-p_C �t au I' _ `r— <br /> PtUin 1,441"4‘10( v �1 <br /> be <br /> i AUG U5 i ' <br /> i.P of Coder isei�, eea oJer *Draliv►fi'tld. 2020 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 lt2 x 11 inches in size —raj 1 <br /> ` <br /> Burnett County <br /> SBD-6398(80313) 1 ,,,,, S,:•;vv-,es Department <br /> CA2.11 ii-;35 '1---47.14 - .. <br />