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.,,:.0.r'0ir;,:., County <br /> Safety and Buildings Division <br /> ; , '-'. 1400 E Washington Ave <br /> 9 Sanitary Permit Number(to be filled in by Co.) <br /> = -., ;RI) r..I P.O.Box 7162 <br /> "'' Madison,WI 53707-7162 <br /> ...�.-'0;,... ::,-::7-$:' <br /> :...i; ;w. '.` C5-r—.20 —3/ <br /> Sanitary Permit Application State Transaction <br /> NumbeerR <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit t 4 O `!J <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 d <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. C. / <br /> N. Application Information—Please Print All Information <br /> Property Owner's Name Parcel# a 7 C� rS' GGG111 o`Z Ifo f'/ egg .2 <br /> k #7 A IQ/tel L Lc. d l o 00 o13e)o <br /> Property Qwner's Tailing Address Property Location/j c / J' 11`5 <br /> .0 0 e r72 66 Govt.Lot <br /> City,State Zip Code Phone Number , <br /> L1 F7///a4/ _ _ /1.)6--- 1/4,11}14..) <, Section ,...,,z g' <br /> p A-4)64,-// W 7 J6 3-�� 8.Sa'/� (circle ons,),„III.Type of Building(check all that apply) Q Lot# T 7 N; R / E o LN) <br /> i or 2 Family Dwelling-Number of Bedrooms C, �J )ie.Cs1� Subdivision Name <br /> AI <br /> Block# <br /> ❑Public/Commercial-Describe Use `-- ✓' ❑ City of <br /> 0 <br /> State Owned-Describe Use '✓ CSM Number 0 Village of <br /> Town of ....5-C-6471.— <br /> .----- <br /> M. <br /> Sc= c4M.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' <br /> I � System iew ❑Replacement System 0 Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> I <br /> , <br /> B• 1 0 Permit Renewal 0 Permit Revision ❑ Change of Plumber ❑Permit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> IBefore Expiration Owner <br /> IV.Type of POINTS System/Component/Device: (Check all that apply) <br /> )'Ton-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.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) • Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> ' -3a0 . 7 171,2% y•5'C3 77 Y. <br /> NII.Tank Info Capacity in Total #of Manufacturer <br /> IL)Gallons Gallons Units }, o 0 <br /> New Tanks Existing Tanks 1i 1 0 .a <br /> 0 <br /> SI A <br /> n,U cn y r, w U P, <br /> Septic or I3etrding-rack /,-1V ee AIfQe) /�'/ /o n t e-s�- <br /> Dosing Chamber <br /> i <br /> VIE.Responsibility Statement- I,the undersigned,assanae 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 /41A-04--- <br /> „/ / _ 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) vv <br /> PO BOX 514,SIREN,WI 54872 <br /> VIII County/Department Use Only <br /> .roved ❑Disapproved Permit Fcc Drat ssu gent Sipa / <br /> I 05 <br /> . / �0 Owner Given Reason for Denial $ )19lo / <br /> IIX.Conditions of Approval/Reasons for Disapproval <br /> * Ot me+ 46 fr wed fir kusumdi w kailaiwiteN �/// i S <br /> oiStkarst,S m ottaat u e, or omAma g Waste. <br /> idage 4 j at h to eco rtp*rns for the system and submit to the County only on paper not less than 8 1/2 x 11 in LeAPR 2 0 2020 <br /> SBD-6398(R0313) , <br /> Burnett County <br /> Land Services Department <br /> /u.ra 14111 111X OD <br />