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C:YpR_rrl::�y',. Count <br /> f., Safety and Buildings Division ]cf/'ti e <br /> c., 74 ''. 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> ` Sft j-,; <br /> \, P.O. Box 7162 S'prN-JD-.24.3 <br /> Madison,WI 53707-7162 <br /> Sanitary <br /> 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 �L"e <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. <br /> I. Application Information-Please Print All Information 5�- <br /> Property Owner's Name f Parcel#C"7 c'/V o2_3.9 /5-is / <br /> Sc,0# Jo Cel A/J S (33 06 3 a,/ 'rte vTr 47/ 6 <br /> Property Owner's Mailing Address J Property Location,C-/ <br /> 31L 7,7 $Ai/'/C? e.0 A Govt.Lot 3 <br /> City,State Zip Code Phone Number y4 <br /> Ake- <br /> / ` 7- -7 ‘67-70--a? /<, Section <br /> S/1 el/ L Ak`e A #' 5J{ f g // 76 5j „isircle one <br /> II.Type of c'.wilding(check all that apply) Lot# T .3g N; R /J E o <br /> t%i or 2 Family Dwelling-Number of Bedrooms — Subdivision Name <br /> ._ Block# <br /> ❑Public/Commercial-Describe Use •— ❑City of <br /> 0 State Owned-Describe Use CSM Number ❑Village of J <br /> 'Town of //9 e,//e 7414e____ <br /> M.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> 1 A. ( 0 New System a lacement System y p y 0 Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. 0 Permit Renewal 0 Permit Revision 0 Change of Plumber 0 Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> 54Non-Pressurized In-Ground 0 Pressurized In-Ground ❑ At-Grade 0 Mound>24 in.of suitable soil 0 Mound<24 in.of suitable soil <br /> 0 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 /> 30 d , 7 4/,2 y y.) y2.V <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units ° Q <br /> New Tanks Existing Tanks c .g R <br /> U in . rn wC -5- <br /> o. .. <br /> Tan <br /> Septic & k -- <br /> p -1.o4ek� . /DLJ /4,00 / /lac/awl(2_5 c Cl) 7`-- <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's SignatureMP/MPRS Number Business Phone Number <br /> WADE RUFSHOLM <br /> -(..)4.'›.-e-4-1 <br /> /4/. ) :4- �”��� 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) //1"` <br /> PO BOX 514,SIREN,WI 54872 <br /> VIII.County/Department Use Only <br /> IX <br /> Approved 0 Disapproved Permit Fee Date Issued Issuing Agent Signatur <br /> e�• <br /> ❑ Owner Given Reason for Denial $ J 7 J. /1— / -40 L✓, <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> z - �e CIdL �Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 s4EC <br /> in size <br /> �• ,- NOV 0 9 2020 J <br /> SBD-6398(80313) <br /> c� Burnett County <br /> (1 Land Services Department <br />