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,.:•tia'-- '.?''s..;-, County <br /> 2< Safety and Buildings Division /-r'�/is jt.' e. <br /> ?: 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> is,- `' P/ -, P.O. Box 7162 g -Z-,273 <br /> " Madison,WI 53707-7162 <br /> Sa,litary 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 m/ailing address) <br /> the Department of Safety and Professional Services. Personal information you provide may be used for secondary .7 O2 3g ��/-G,2, kc <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. <br /> I. Application Information-Please Print All Information _ <br /> Property Owner's Name Parcel# 07 (.9/.: o? Ve--) / 3S <br /> bi)I e_y fro? e.(\I.-/ 3- �c.- o S cie,C C, /APO <br /> Property Owner's Mailing Address Property Location pc.,/ V1'4.D j <br /> /(7 dam' 45-07Y) 5Y-- Govt.Lot e <br /> City,State Zip Code Phone Number `7/'5- , <br /> �/p /, /<, Section ,3 -- <br /> S 611I4.1'.5E'_`-- a),, V5- 0 v� S 7 / 7.., e/3 .,(circle one <br /> II.Type of Building(check all that apply) 7 Lot# T i'-/e) N; R/ E or h! <br /> l or 2 Family Dwelling-Number of Bedrooms 3 Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use ❑ City of '— <br /> ❑State Owned-Describe Use CSM Number 0 Village of <br /> -'Town of \I-39•C-k„.5.0") <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> + <br /> A. 0 New % <br /> System Re Iacement System y p y:. 0 Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> I <br /> B. ' 1-1 List Renewal 0 Permit Revision <br /> 0 Change of Plumber 0 Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of Pz**WI'S System/Component/Device: (Check all that apply) <br /> Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil 0 Mound<24 in.of suitable soil <br /> ❑ Holding Tank 0 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(st) System Elevation <br /> -5-0 / 7 6 5'3 65-..) ?.: '�Z <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units L (.5o b o <br /> New Tanks Existing Tanks w c " R vi <br /> 6 SLI <br /> a. U inn y rn w C7 a. <br /> , Septic or an //e571:,Q .._. 49ii) / /t/,t )n/�GL�e-s G C� „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 Signatur MP/MPRS Number Business Phone Number <br /> WADE RUFSHOLM `,� 6 �,- 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) if l�4 <br /> PO BOX 514,SIREN,WI 54872 <br /> VIII.County/Department Use Only <br /> 4 Approved 0 Disapproved Permit Fee Date Issued Issuing Agent Sign e <br /> 0 Owner Given Reason for Denial $ S' /2'a •2l'/ <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> �t�� �i ICf y -3-75-- <br /> DAttatn <br /> ch to complete plans for the system and submit to the County only on paper not less 2 x tE se 2020 <br /> SBD-6398(R0313) <br /> ` [i7 <br /> Burnett County <br /> Land Services Department <br />