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' t County <br /> �C J <br /> = Safety and Buildings Division �f^Je-!/ <br /> 0 S _ 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> "' ,ti ! Madison,WI 53707-7162 S N Da-l 3l, <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) <br /> the Department of Safety and Professional Servies. Personal information you provide may be used for secondary ,3�y" j <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. C <br /> 1. Application information-Please Print All Information • <br /> Property Owner's Name Parcel#d 7 O o 6 , . 39 /7/8/ <br /> C,Al ry G.oc)e. .l,4n1T <br /> VA- c.A 4 rC.._. CP3 ©0E9 6/a°00 <br /> Property Owner's Mailing Address- Property Location pc_/ <br /> !I/� S , <br /> 3r) ; /?ei 7o Govt.Lot <br /> City,State Zip Code Phone Number /J A-r- . � �� g <br /> / �J4/ / �'a� /<, /<, Section / <br /> / �"44J+ qr. !� 5 //17/0 /tz d t—lair (circle one <br /> H.Type of Buildinrheck all that apply) Lot# T 3 N; R1 E o� <br /> V*-or 2 Family Dwelling-Number of Bedrooms I/ ,.---- Subdivision Name <br /> �- Block# <br /> ❑Public/Commercial-Describe Use ❑ City of .---- <br /> CSM Number ❑Village of <br /> ❑State Owned-Describe Use ,,lr�� <br /> Town of tiU 4-/t)1 e./5 <br /> III.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 <br /> 1 ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> B. ❑Permit Renewal ❑ Permit Revision <br /> i Before Expiration ( Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑At-Grade .Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑ 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 /> 600 / C o 0 o 6 9e,.rvZ <br /> VI.Tank info ( Capacity in Total #of Manufacturer <br /> Gallons Gallons Units L o <br /> C.)New Tanks Existing Tanks . o a; 8 p <br /> rt U in w cii u. C7 ii <br /> Septic or /2�a <br /> r <br /> /e5e,r Dosing Chamber 73-a �- 75-12 <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 c2 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 /> Permit Fee p0 Date Issued +aIsIt Signat <br /> rApproved ❑ Disapproved sips '' 7/?? I! <br /> i ❑ Owner Given Reason for Denial <br /> IX./ Conditions ofApprro`va eas s for Disapproval (git lJ W [Cn\ <br /> Meek l .J7 ei, I k (01 <br /> ti-(,)69° FJUN 2 3 2022 g <br /> Attach to completeplans for the system and submit to the County onlyon paper not less than 8 r x 11 in es in size I <br /> P Y ty P P <br /> Burnett County <br /> Land Services Department <br /> SBD-6398(R. 11/11) . <br />