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,.rsrur ;. County <br /> .,.,.. <br /> Safety and Buildings Division ee/,'^Jv n <br /> /It <br /> Di 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> C., a to i'' P.O.Box 7162 YP(N—21> Z <br /> Madison,WI 53707-7162 , 9Z7 <br /> Sanitary Permit it Application State Transaction Number <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 /' <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. , 6- c:_,6 C /l_. Ac <br /> E. Application Information-Please Print All Information <br /> Property Owner's Name <br /> y� /� / /, Parcel# G 7 c ,2 U ..l Yv /6 0 <br /> IT�i401 \.J !1$l� 0/S/� / ' f c)..)—C90S-0/1000 <br /> Property Owner's Mailing Address Property Location /0 c./ 1 Z.S5-3 <br /> J / 9 419_.t.t.) /{id 1L Govt.Lot 3 <br /> 3 City,State Zip Code Phone Number <br /> 1 p / _ /<, /a, Section .Z <br /> 1 F//Gtll�elide.i /1)4 <br /> .`J 3Cl O z (j5/ ei 05 / /�9 ? �/ (circle one <br /> J T_ 7e N; R/k7 Eor <br /> IL Type of h:wilding(check all that apply) Lot# <br /> or 2 Family Dwelling-Number of Bedrooms ' / Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number 0 Village of �i <br /> t/ 3 11) V Town of 074/`/!4-/C/ / <br /> nil.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> 0 New System IF.iReplacement System 0 Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> 1 <br /> H. 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 /> ay.Type of?"WTS System/Component/Device: (Check all that apply) <br /> Non-Pressurized In-Ground 0 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 /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> ' y:5-e) : 7 '/3 6..6 e' 7 7 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units s, o°b„ <br /> New Tanks Existing Tanks „o L <br /> w U in ,,, co <br /> w D a. <br /> Septic or Hat k 3-"W 7.5-42 <br /> 5 C2 /al%7 2 ,/44//174-A--rL LC *_ 74- <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's Signature MP/MPRS Number Business Phone Number <br /> WADE RUFSHOLM /// // /L"'' ''-1 ."- 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) �� <br /> PO BOX 514,SIREN,WI 54872 <br /> I VIIII.County/Department Use Only <br /> Approved ❑ Disapproved Permit Fee Date Issued Issuingg Agent Signa <br /> ID Owner Given Reason for Denial $ ��' 7.--: 7•2p [/V • <br /> j <br /> IX.Conditions of Approval/Reasons for I isapproval I'7444"1 *-4a,� <br /> iD <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x . in in C 0 1 20213 <br /> SBD-6398(R0313) <br /> Burnett County <br /> Land Services Department <br />