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rr Co t <br /> y <br /> !' Safety and Buildings Division �(--/r/L1 r'.. /r <br /> 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> \ ". P.O. Box 7162 20-22 <br /> Madison,W 153707-7162 t <br /> .,F':; r '.. / _s-r—t2o—/ V <br /> Sanitary 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 PLJTs• /D ZD a 2 37 t/'I C, <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 actress) <br /> the Department of Safety and Professional Services. Personal information you provide may be used for secondary /0 6.27 77/42,,,,c e L1(/t/ <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. ✓J 7� --1 Q <br /> E. Application Information-Please Print All Information I / <br /> Property Owner's Name / 1 Parcel#6 7 O 44,2 2 yrL�/ 402- I <br /> 5ofG, /! 0 S4a A r d'� o el COC) cT/.z O0 0 <br /> PropertyiOwner's Mailing Address ( Property Location /0 C_ <br /> 4.2"7.22 S J� A-A),'� -e, 4./ /IJ e 10 Govt.Lot <br /> City,State \ IZip Code / Phone Number 7 _,5--e" 1, N /, Section 1;2_GJr�}',>) <br /> I - 4 Ili/^� y (:G)- 'To 6 r 9__,z 3/ 5� (circle one <br /> I EL Type of Building(checli`'[➢l that apply) e� Lot# T 2� N; R � E o <br /> Aor 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 p / <br /> ,---- ❑Town of 6)0E,e/ A /ti e-/--' <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. 1New System El Replacement System 0 Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> B. i 0 Permit Renewal 0 Permit Revision ❑ Change of Plumber 0 Permit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS Sjistem/Component/Device: (Check all that apply) <br /> ❑Non-Pressurized In-Ground 0 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) 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 /> __30u / 3 C -_a d iiY) 7 <br /> VI.Tank Info Capacity in Total #of Manufacturer t> <br /> Gallons Gallons Units �, o o c) <br /> New Tanks Existing Tanks y c o g3 <br /> aU n . so ts. c7 a <br /> Septic or I-IaWiag�ank 32 C, c--- Q yor i / <br /> Dosing Chamber 5-0 0 `J—t l j W �� �i r /x_ <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 Signat eMP/MPRS Number Business Phone Number <br /> WADE RUFSHOLM i/I ����T„-.` 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 <br /> VIII.County/Department Use Only <br /> Approved 0 Disapproved Permit Feer' Date Issued Issuinggent Sign e <br /> \ ❑ Owner Given Reason for Denial `5 /0—5'-7-Z) <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> 151-1-3c. 3 4 <br /> DIZCEOVIED <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 . 1 es in size <br /> CC T 06 2023 i <br /> SBD-6398(R0313) <br /> Burnett County <br /> Land Services Department <br />