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i .,,,,.::-:,,;,,i, County," <br /> I Safety and Buildings Division Qa(,I/`00e <br /> % D. 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> ' `...,,,bp S Madison, WI 53707-7162 S�N'o+�" r( <br /> /1 O <br /> 468D73 <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 g Pi-3/ <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. RaiI. Application Information-Please Print All Information lit). R 55 LaIC'� Il <br /> Property Owner's Name Parcel# 0 7 0/ a A q 0 /5'a,3 <br /> pPKi:'el Elli ce 11 0 a 000 ©/8 aoa <br /> Property Owner's Mailing Address Property Location #O e.,/ -Tax t 55 i, <br /> o.?s L o Mi q Rd Govt.Lot A. <br /> City,State J Zip Code Phone Number y4 3 <br /> j� -�r �(J A/ 56- /<, Section i� <br /> N/VGl/O G/ to.!� ��7 7.3 T VD N; R ircle oq <br /> II.Type of Building(che all that apply) Lot# E o <br /> WI or 2 Family Dwelling-Number of Bedrooms c- 11 Subdivision Name <br /> �, Block# <br /> ❑Public/Commercial-Describe Use <br /> { ..--- <br /> ❑ City of <br /> ❑ Villa <br /> ❑State Owned-Describe Use CSM NumberVillage of �-t� <br /> / n� 23 VTownof v ! 'LI(S O,e(-) <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. 1 ❑New System 5 Replacement System Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> i <br /> 1 <br /> I E List Previous Permit Number and Date Issued <br /> B. ! ❑'Permit Renewal i ❑ Permit Revision ❑ Change of Plumber ❑Permit Transfer to New <br /> Before Expiration Owner I NV <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 /> gHolding 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 /> ao 0 '— <br /> ? VI.Tank Info Capacity in Total #of Manufacturer <br /> o <br /> Gallons Gallons Units 1, B o <br /> New Tanks Existing Tanks y o U Y <br /> w y bis A <br /> U rn , a 3 �, <br /> Seimor Holding Tank BCD ae00 l IA)/es el- 7‘--- <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 /e) 227691 715-349-7286 <br /> �ji/ <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX 514.SIREN,WI 54872 <br /> VIII.County/Department Use Only <br /> XApproved ❑ Disapproved Permit Fee IDpate Issued Is Agent Signatu <br /> q4k - .---) <br /> 1 ❑ Owner Given Reason for Denial $`7 '`�'J1��� <br /> IX.Conditions of Approval/Reasons for Disapproval -` v C V <br /> l� <br /> 1 V e - c SO-loci( S <br /> �I�Ow art ceurt+-1 a -it.-k re 'ui e- �' J <br /> tfol t✓l i -I-et 11 lc- -(-o se,rt,;ce d an n u JUN 0 2024 <br /> Attach to complete plans for the system and submit to a County only on paper not less than 8 1/2 x 11 nches ij_size <br /> Burnett County <br /> Land Services Department <br /> SBD-6398(R. i I/I 1) It 616 cJ ,ar - 1 u8 AI <br />