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;q,ir-- <br /> Count <br /> ;. _ ..;:P,-;:is.:, <br /> ,. Safety and Buildings Division a r/ti e, <br /> _ �K' 1400 E Washington Ave <br /> �, g Sanitary Permit Number(to be filled in by Co.) <br /> ' C,. ;,' j •i P.O.Box7162 ,3A�y a 1 -35K 644592, <br /> :, Madison,WI 53707-7162 <br /> .: <br /> _ C---02/ ^_.28'7 <br /> State Transaction Number <br /> Sanitary Permit Ap-i1ication <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of thus form to the appropriate governmental unit QW 1.5— 1 2.22.0 3 1 Q 2.-L <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 /> { <br /> the Department of Safety and Professional Services. Personal information you provide may be used for secondary 7 7 oZ Cl <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. ,p GT /�/V 1 <br /> L AppllicationIInformation-PleasePrintAllIInformation Pros f '1 <br /> Property Owner's Name / 1 Parcel# es 7 p a c ®2 c/0 /6 <br /> grie_kso4) CoMMerc/4/4.`- C- 0010 5- /$- 93/ 0170364 <br /> Property Owner's Mailing Address Property Location <br /> AO g a eK �//Y <br /> Govt.Lot <br /> City,State Zip Code Phone Number 1/4 /iq Section o <br /> (j(/ q <br /> { e is 'e--r 1-ei o' " /'3 7'5 3 77 -?ss' //circle one <br /> )„.-N y0 N; R f 6110E or N, <br /> E.Type pe off i::minding(check all that apply) Lot# <br /> 3 Subdivision Name <br /> 0 1 or 2 Family Dwelling-Number of Bedrooms <br /> Block# <br /> 'ublic/Commercial-Describe Use /L/ C AMP-5/1'et5 ❑ City of -'� <br /> ❑State Owned-Describe Use CSM Number 0 Village of �j" <br /> va 3 f 7 s. <br /> 02 (Town of 0 I\r/04"4)d <br /> ice.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' j ❑New System 'Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> i ! List Previous Permit Number and Date issued <br /> B. ❑ Permit Renewal ❑Permit Revision ❑Change of Plumber 0 Permit Transfer to New <br /> Before Expiration Owner <br /> { <br /> Pi.Type of POWTS System/Component/Device: (Check all that apply) <br /> Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade 0 Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> Pickling rioiding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dismersal/Treatnnent Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 630 # 7 70 c) •0d 95. V- <br /> II.Tank info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units ,a ao'3 <br /> New Tanks Existing Tanks v o . y °� a <br /> aU co ti co ill c..., a, <br /> Septic or IielQfigic I �/ <br /> 6 <br /> .-- 6f�/S r --,4-- <br /> Dosing Chamber 000 i /00 / /I <br /> WE.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 ) / ‘`^!_ 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) ljt//G� �i ��/� <br /> PO BOX 514,SIREN,WI 54872 <br /> VIII.County/Department Use Only <br /> Per it Fee <br /> .J ) 5) / jssued , •geSignats�1pproved ❑Disapproved©Owner Given Reason for Denial $_ 5 'A� j ' <br /> IL Conditions of Approval/Reasons for Disapproval �'b /// a (� t!�- 3 <br /> ' <br /> ETECIEOVE ---1 i <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 in x 1stla g(� 1 U 21 21 '' <br /> SBD-6398(R0313) v �i J <br /> Burnett County <br /> Land Services Department <br />