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County <br /> Safety and Buildings Division <br /> >~ 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> P.O.Box 7162 <br /> Madison,WI 53707-7162 4- <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 &A01,;t8 <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 Services. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s.15.04 1 m,Stats. <br /> 1. Application Information-]Tease Print All Information <br /> Property Owner's Name ( Parcel# ©7 6 G' 02 3 8 /7,;ZO <br /> /'71 pc�/3�®�, �39� <br /> Property Owner's Mailing Address Property Location/ ci <br /> ® :S' A,e-/Y7 P/ /)C1' Govt.Lot <br /> City,Sta e Zip Code Phone Number / <br /> tre aJ� 5 �g 7� I �7, O��� section����' (circle one" <br /> one <br /> T <br /> II.Type of Building(check a➢➢that apply) Lot# —N; R E o <br /> or 2 Family Dwelling-Number of Bedrooms "' Subdivision Name <br /> Block# <br /> ❑Public/Cornmercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of �1 <br /> 19 Town of ,4N l S <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' ❑New System Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <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 /> W.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.IDis ersa➢/Treatment Area Information: <br /> Design Flow(gpd) Design Soll pplication Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> III.Tank Info Capacity in Total #of Manufacturer L <br /> l Gallons Gallons Units o° <br /> New Tanks Existing Tanks o B y ACIS <br /> a U zn �, vi iw C7 P, <br /> Septic or Id an, / G' „� -9 r <br /> Dosing Chamber C <br /> VIII.Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plum Signature MP/MPRS Number Business Phone Number <br /> WADE RUFSHOLM /� (�/� 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 <br /> VVIII.Coun /IBe artment Use Only <br /> �pprovcd ❑ Disapproved Permit Fee Date sued suin Agent 'gnature <br /> $375.00 <br /> El Owner Given Reason for Denial <br /> !D 2� 2011 ' <br /> IX.Conditions of Approval/Reasons for➢Disapprov ➢ <br /> w�c�s,{ be 1�a! <br /> OCT 7 2019 <br /> Attach to complete plans for the system and submit to the County only on paper not less than Illox ?nches in size <br /> 1 <br /> SBD-6398(R0313) Burnett County <br /> Land Services Department <br /> Tay <br />