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1 ;i,., ,r-,:y County <br /> i ''': Safety and Buildings Division ,a .,/`rt.1 e. <br /> il- <br /> 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> `"ti P • ' Madison,WI 53707-7162 - 2 p 2 640645 <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 <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) Q <br /> the Department of Safety and Professional Servies. Personal information you provide may be used for secondary ./ . 335O5 <br /> purposes in accordance with the Privacy Law,s. 15.04(I)(m),Stats. P,'rk <br /> e.I. Application Information—Please Print All Information . <br /> Property Owner's Name Parcel# 0 7 0,-1 L` ,2 4/0 /& / 1 <br /> L e- 0 C c11 c>.5 /6` 3''e , L3i0c3 <br /> Property Owner's Mailing Address Property Location />-_f <br /> 9 51 <br /> &/-.A A=,-)1 A'Vit_ Govt.Lot <br /> City,State Zip Code Phone Number y, /4, Section Y <br /> .� Q j (circle one <br /> 5/� / N� `� ��� 5 T 4/0 N; R lk E oe <br /> II.Type of Building(check all that apply) Lot# <br /> p4-or 2 Family Dwelling—Number of Bedrooms (/ Subdivision Name <br /> '_ Block# <br /> ❑Public/Commercial—Describe Use ❑City of <br /> CSM Number ❑ Village of <br /> ❑State Owned—Describe Use <br /> t/2 <br /> /2/j, f �'47' gTown of Q��//n'/Ur' <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable)/ <br /> A. I lew System ❑Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> � ❑ Permit Renewal ❑Permit Revision DI of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> B. <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> on-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade Cl Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> 1 ❑ 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 /> /.5-0 , 7 /. - Z) 76 <br /> VI.Tank Info Capacity in Total #of Manufacturer Y <br /> Gallons Gallons Unitsr, 0 c <br /> New Tanks Existing Tanks a) o8 Y p R <br /> atU in y w3 0. <br /> Septic or 0(,L.) ^ /i)CAD / /V cr;'.'fe S C- LSI <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 Signature MP/MPRS Number Business Phone Number <br /> WADE RUFSHOLM l/ 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) +��—��----- <br /> 1 PO BOX 514,SIREN,WI 54872 <br /> i <br /> VIII.County/Department Use Only 7 <br /> Permit FeeDate Issued Issuing Agen •ignatur- <br /> Z Approved CI Disapproved d� <br /> air <br /> CI Owner Given Reason for Denial $ 1125 -- I i)0 1;'40)" 111 ' - <br /> IX.Conditions of Approval/Reasons for Disapproval ' 5 <br /> �IJ�Y MGG 0.�� 5��b0.L�S <br /> 1 11) 7CEOVIE .Th <br /> 0 <br /> j AN1U2022 <br /> Attach to complete plans ffor the system and submit to the County only on paper not less than S 1/2 xize ,J <br /> Burnett County <br /> SBD-6398(R. 11/11) Land Services Department <br />