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County , <br /> ' Safety and Buildings Division <br /> 1400 E Washington Ave <br /> 9 Sanitary Permit Number(to be filled in by Co.) <br /> P.O.Box7162 <br /> Madison,WI 53707-7162 <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 fonns for state-owned POWTS are submitted to Project Address(if different than mailing address) <br /> the Department of Safety and Professional Services. Personal information you provide may be used for secondary <br /> oses in accordance with the Privacy Law,s.15.04 1 m),Stats. C, <br /> II. Application Information—Please]Print An Information <br /> Property Owner's Name Parcel# 0 ] 0 O a .3 i7 .21 <br /> /e,J -ZY <br /> Property Own ailing Address Property Location <br /> 3 J 6/ t-l 65Le—. Govt.Lot <br /> City,State Zip Code Phone Number /4 /4, Section <br /> e A) j'�3 6 /a/ -V�6 -Z. (circle one <br /> / _� <br /> 7[II.hype mi➢dung(check all that apply) � Lot# T N; R Z E oe, <br /> ❑ 1 or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of <br /> AITownof {/f}/Ujj0 ,5 <br /> HR.Type of]Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' 9Vew System ❑Replacement System g p y g y (explain) <br /> // `` ❑ Treatment/Holding Tank Replacement Only El Modification to Existing System <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> TV..Type of POWTS System/Component/Device: (Check all that apply) <br /> J2(`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.Dis ersa➢/'II'reatmIlent Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> Rol.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o <br /> Ncw Tanks Existing Tanks o 0 E B <br /> a U in y w C7 w <br /> Septic or <br /> Dosing Chamber <br /> VIIt.Responsibility Statement- ff,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP S Number Business Phone Number <br /> WADE RUFSHOLM f 1t A' 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 <br /> VIDI.Count /De artnment Use Only <br /> Approved ❑ Disapproved Permit Fee Date Issued Issuim AgeptiSignature <br /> ❑ Owner Given Reason for Denial i <br /> EIS.Condlitiom ff s s for Disapproval <br /> ED EIVRE <br /> '6� <br /> n F,,,, r WIQ I <br /> Attach to complete plans for a system and submitto ounty only on paper not less than 8 t/2 x I dWin <br /> SBD-6398(R0313) /8'i"� <br /> C �� <br /> Burnett County <br /> 7 �"/ Land services Department <br />