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.. County) <br /> Safety and Buildings Division e/i"/;J i. <br /> il— <br /> • �., 1400 E Washington Ave <br /> • `�l�;, 9 QSanitary Permit Number(to be filled in by Co.) <br /> . ` `` ', I'! P.O.Box7162 JAW'oW...gl <br /> Madison,WI 53707-7162 <br /> 3amitary Permit Application• State Transaction Number <br /> (03744 <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 Services. Personal information you provide may be used for secondary ay. ,0 7 - a ?,6/3 <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. J <br /> ( If. Application Information-Please Print Ali Information L.e'/l-'(d J..K --r It 22200 <br /> Property Owner's Name j Parcel# 0 7 0;3'2 .2 4'//(' 3 Y g' <br /> Tymoo t 577/. /m <br /> . 0_5— co3 o/g Oc90 <br /> Pro e ty Owner's Mailing,Address Property Location/9 c.-.../ <br /> 41 L/3c /1 4/ * Govt.Lot 3 City,State1J Zip Code Phone Number /J y, %M Section Y <br /> C-/91�1(jf'1 <br /> s5E= : l7 <br /> , .�S© T -7 t/ N; R /L/`(circleeoone,) , <br /> 1i1.Type of Building(check all that apply) / Lot# , <br /> r 2 Family Dwelling-Number of Bedrooms �! Subdivision Name <br /> _�� Block# <br /> 11mm <br /> Public/Coercial-Describe Use <br /> ❑City of <br /> 1 CSM Number ❑Village of r <br /> State,_: Owned-Describe Use <br /> 7 yy Town of -5-4c-ii-05 <br /> V <br /> fill.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A• i ❑New System 7LReplaeement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> l � <br /> i I <br /> ii. i 0 Permit Renewal ❑Permit Revision ❑ Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IVY.Type of POWTS TS System/Component/Device: (Check all that apply) <br /> Noi-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> } s i 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 /> (Dov - 7 �f00 97/f <br /> VI Tank Info 1 Capacity in Total #of Manufacturer <br /> Gallons Gallons Units a o o <br /> New Tanks Existing Tanks '' o 1j g 7 <br /> 0 <br /> +w ti cn co en w c7 a, <br /> Septic or f3eidirr enk /.2 S /1 ,— /o25 Ci / 6d/ <br /> e-5 <br /> e. - <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 SignatureMP/MPRS Number Business Phone Number <br /> WADE RUFSHOLM 227691 715-349-7286 <br /> } Plum'ber's Address(Street,City,State,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 <br /> VJi.County/IDepartnnent Use Only <br /> lPermit Fee Da a Iss ed suing ent Signature4lpproved 1 ❑Disapproved $31-5 (,, <br /> Li Owner Given Reason for Denial �/ � �}O <br /> I IX.Conditions of Approval/Reasons for Disapproval <br /> 442;11 J must home access is be se v►'eece. i� 1E 0 d E 7 <br /> 4,Fxi <br /> 4 ,44 Ttors it he ekomflobtdeci per SAS. AY D r <br /> $ AN vwosstrtat5 f 1st S+4,kc rtppte�/ai. MAY 1 9 2020 4 <br /> Attach to complete plans ffor the system and submit to the County only on paper not less than 8 112• i in size r./ <br /> - <br /> Burnett County <br /> SBD-6398 9e(R0313) <br /> Land Services Q.atinlbnt <br /> 6elt 15251 $425.00 <br />