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County <br /> Safety and Buildings Division ,614 i - <br /> S 201 W.Washington Ave., P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> Madison,WI 53707-7162 4n. —22 1 <br /> :f;> 1101 <br /> StateTransaction NumberSanitary Permit Application <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 7 ey/ <br /> purposes in accordance with the Privacy Law,s. 15.04(I)(m),Stats. /,, Q <br /> 1. Application Information-Please Print All Information Cit..A-( .s/C �1 <br /> Property Owner's Name Parcel# 0 7 0/2 2 ye/6.-• ?8' .3.- <br /> _.. A1A)4 1--.4-L1INec- /5' lee 6:3;ZGc'u <br /> Property/ Owner's Mailing Address Property Location,L2 <br /> p��f�1_c�JJ—�'A 5t Govt.Lot <br /> IF City,�Stateta Zip Code Phone Number c� y, /4, Section p�� <br /> 5Ci-f / /y)4) 15-57/q ‘ " 76 7� 7i (circle one <br /> IL Type of Building(check all that apply) Lot# T `fll N; R / E o VJ <br /> 0 or 2 Family Dwelling-Number of Bedrooms c.2 ) Subdivision Name ,/ <br /> Block# G /�'/�/� 5/C7 4c.re-5 <br /> ❑Public/Commercial-Describe Use ❑ City of <br /> ❑State Owned-Describe Use —... CSM Number ❑ Village of J. <br /> J <br /> own of �J 4 e-KS CS - <br /> ) <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. vz <br /> New System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> List Previous Permit Number and Date Issued <br /> B. f ❑ Permit Renewal ❑Permit Revision ❑ Change of Plumber ❑Permit Transfer to New <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> Jon-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) I Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> oo 1r 7 1 y;9 9� e-' J. <br /> VI.Tank Info Capacity in Total #of Manufacturer 1 <br /> Gallons Gallons Units a) o ,' 0 <br /> New Tanks Existing Tanks y c 0 2 y 2 c <br /> L U iii �, v� w 3 r% <br /> Septic or Holek..b Tact' 7 e - $C) / i <br /> �v S iv i e5 =^ • A <br /> Dosing Chamber 5 D v S®0 <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 / 227691 715-349-7286 <br /> ett <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 <br /> VIII.County/Department Use Only <br /> y�lpproved ❑ Disapproved Permit Fee Date Issued Is in Age Signatur <br /> $ ya5 gird' <br /> _� ❑Owner Given Reason for Denial <br /> IX.Conditions of Approval/Reasons fo Disapproval "_ <br /> 46 j <br /> AUG 3 1 2022 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 inchetn s t -J/ <br /> Burnett County —/ <br /> SBD-6398(R. 11/11) Land Services Department <br />