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,airrsi ,;;, County • <br /> Safety and Buildings Division Li,'/lie-'7 <br /> 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> �� "i P.O.Box 7162 c ,,�� b <br /> Madison,WI 53707-7162 <br /> c�l'�l`� — �� `o <br /> State Transaction Number <br /> Say iitary Permit Application GAb&a/4 <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 different than mailing address) <br /> the Department of Safety and Professional Services. Personal information you provide may be used for secondary //$c _e) n I <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. <br /> I. Application Information-Please Print All Information /ey) -y <br /> Property Owner's Name Parcel# Q`7 0 3(7/ DZ .3 7 i4ei 6 f <br /> e F p /S ex) 5%0/ 004 e2//0001:'x3251 - <br /> Property Owner's Mailing Address Property Location ,61 <br /> 3 `16 y3 f'A�lin 51:: A)ct) _ -/ <br /> Govt.Lot <br /> City,State t Zip Code Phone Number <br /> /tJc /<, 5e` /<, Section <br /> s 4/4/J Gk'fPei() rn 4 5-5-03 0 (circle one <br /> T 37 N; R /5' E o> ) <br /> II.Type of Building(cheek all that apply) Lot# <br /> 1 or 2 Family Dwelling-Number of Bedrooms 'S/i oi° Subdivision Name <br /> I Block 4 <br /> ❑Public/Commercial-Describe Use ---- ❑ City of ' <br /> --_-- CSM Number ❑ Village of ------ <br /> ❑State Owned-Describe Use / <br /> ----- 7STown of 7/'/{Com!e_- LA/e.. <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. icNew System ❑ Replacement System y p y 0 Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑Permit Revision 0 Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Con ponent/Device: (Check all that apply) <br /> ❑ Non-Pressurized In-Ground 0 Pressurized In-Ground ❑ At-Grade 0 Mound>24 in.of suitable soil ❑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 /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units � L U �, <br /> New Tanks Existing Tanks 0 o 2 E . R <br /> '0:1 c..) in y cn w3 a, <br /> e-or Holding Tank _ <br /> Dosing Chamber <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber' Signature MP/MPRS Number Business Phone Number <br /> WADE RUFSHOLM z, 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 <br /> VIII.County/Department Use Only <br /> Permit Fee Date I sued suing A:-nt Signa e / / <br /> �4pproved ❑ Disapproved $ �7fI' co � /� ��Iq I i / <br /> (/ -� <br /> ❑ Owner Given Reason for Denial <br /> I X.Conditions of Approval/Reasons for Disapproval <br /> c tc; L .s 37 , <br /> APPROVED <br /> IECEEIVE1 Attach to complete plans for the system and submit to the County only on paper not less than 8 1ches jppgt82019 / <br /> CJLLLLIU ! u `� JSBD-6398(80313) Burnett County <br /> Land Services Department <br />