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... ._ib:Zl,.., <br /> : Safety and Buildings Division 6urA) e- <br /> ',.,. 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.)7.3 T..., H P.O.Box7162 SRN-.21-e2'37 X37429 <br /> Madison,WI 53707-7162 <br /> Sana Permit Application StateTransactionNumber oL <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit $Z V d 7 8 <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 2 3 a/ig 4 2.7 Z•5 <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. <br /> L Application Information-Please Print All Information Goy 4-4) <br /> Property Owner's Name / /f Parcel# o'7 0 O b o2 .3u /7 30 <br /> /! �� 1 rDi'►'1 b i I' d'3 ("coo o/3ac>'O <br /> Property Owner's Mailing Address Property Location A G./ <br /> / 5-6/ /wy 96 Govt.Lot <br /> City,State Zip Code Phone Number Aka-) y., Section .30 <br /> 1�/1/fe i e4r LK /PA] 5-57/O 6S/ - 7 <br /> p /3 (circleone <br /> IL Type of Building(check all that apply) Lot# T 3' <br /> O N; 12.17 E o U/ <br /> .)kor 2 Family Dwelling-Number of Bedrooms -3 Subdivision Name <br /> Block# <br /> { Public/Commercial-Describe Use — <br /> ! ❑City of <br /> CSM Number 0 Village of <br /> 0 State Owned-Describe Use ../ <br /> ( Town of 4 A/o/e1.5 <br /> EI.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' i 0 New System Replacement System 0 Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> ''3- I 0 Permit Renewal ❑Permit Revision ❑ Change of Plumber 0 Permit Transfer to N List Previous Permit Number and Date Issued <br /> 1 Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> El Non-Pressurized In-Ground 0 Pressurized In-Ground ❑ At-Grade 0 Mound>24 in.of suitable soil Mound<24 in.of suitable soil <br /> ?i Holding Tank 0 Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Designow(gpd) Design SIApplication Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> V5- <br /> u .52/.5-6') <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units " ,d ,'0 o <br /> New Tanks Existing Tanks d <br /> { y 2 lil <br /> o p <br /> ,O C<-5 w cc w c7 <br /> a, <br /> Septic or Holding Tank A : 00 /Oa> f /e.5 e t y� <br /> Dosing Chamber / f 1 <br /> 7.SU 7S b / L+JO�5 e/" -?1-- <br /> R/11.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumbe's Signature <br /> Number Business Phone Number <br /> WADE RUFSHOLM p �y� 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> �/ <br /> PO BOX 514,SIREN,WI 54872 <br /> ` III.County/Department Use Only <br /> 0 Approved 0 Disapproved Permit ee Date •Issued _ nt Sign.. .- <br /> f! ❑Owner Given Reason for Denial $Li <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> / <br /> 1A4skr mee, 5° set bask. ' o ponce. ECEOWED <br /> 'M,,s c rv►ee- 50, 5tjc back *-o we\\. <br /> AUG 2 6 2021 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 812 i_i i,;_ in size <br /> 1 <br /> SBD-6398(80313) Burnett County <br /> Land Services Department <br /> G \< #. i5-2t? <br />