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County <br /> Safety and Buildings Division Z elf 1i e— <br /> '/ 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> " P.O.Box 7162 AO_� 0 <br /> Madison,WI 53707-7162 ��� -� <br /> Say 1 itary 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 _____-. <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. J�7 j ` // 0 r <br /> 8. Application Information-Please Print All Information <br /> / r <br /> Property Owner's Name Parcel# O 7 0 3,,Z ,..7 y/ /6 7 <br /> ,+-,i) 1 [^ 7 o c' a/Ze es <br /> ' Property Owner's Mailing Address Property Location�p 22DZJ7 <br /> y7Va sVn�L,4-ro /4ce Govt.Lot <br /> City,State Zip Code Phone Number _514.) y4 A! 6"." /, Section p2 7 <br /> I 1 e H„o MA) 5 (4,2Y /1,3 v�73 C/1 /,z,75.— T ` circlEe oone <br /> ) <br /> I IIII.Type of Building(check all that apply) Lot# 7�� N; R �� <br /> VI or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block# <br /> ©Public/Commercial-Describe Use ❑ City of <br /> ❑State Owned-Describe Use <br /> CSM Number 0 Village of <br /> V / <br /> / Q 7 own of .5[.t- /S.5 <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. 0 New System ?I-Replacement System�a p y 0 Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> I _ <br /> B. 0 Permit Renewal 0 Permit Revision 0 Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> P7.Type of POWTS System/Component/Device: (Check all that apply) <br /> 1Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade 0 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 /> V5-0 : 7 Gy 3 C 5-0 9.5:, <br /> VII.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units 2a6 o b 0 <br /> New Tanks Existing Tanks . c B f XiR m <br /> w U Enco i <br /> Septic or 14eldtrrJr'anic /,o C) / !/ <br /> .l / ai ` r �� <br /> v <br /> Dosing Chamber /O d _...-- op <br /> VII.Responsibility Statement- II,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 f / �7,� 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) /�/Z�L� <br /> PO BOX 514,SIREN,WI 54872 <br /> IVIE County/Department Use Only <br /> dCl Approved ❑ Disapproved Permit Fee Date Issued Issui gentgnature <br /> \ <br /> 0 Owner Given Reason for Denial $J-i 5:-. 1 2. • '-z D `t <br /> IX.Conditions of Approval/Reasons for !bisapproval �C 11-94 <br /> I I 1' 375 <br /> ECIEOVE <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x inc in sr/CC 03 2020 <br /> SBD-6398(R0313) • <br /> Burnett County <br /> Land Services Department <br />