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,, ,,_Kr,,ii County <br /> Safety and Buildings Division f� <br /> County <br /> �7 <br /> =. K 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> F� P.O. Box 7162 _ 1 <br /> ._.. Madison, W 153707-7162 N— `3 <br /> ?F!`5H 1'..14.';' <br /> Sanitary Permit Application StateTransacltionNumber <br /> 2.0 <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 a y_57„,z <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. L / <br /> I. Application Information-Please Print All Information �/l'G.v e. 'L� LAI <br /> A <br /> Property Owner's Name Parcel# a 7 0_76'2 y0 /7 /3 s-- <br /> •8 /04 Ao -Tr'as71' /5' 600 a/900o r124St <br /> Property Owner's Mailing Address Property Location <br /> fro ddb 3> Govt.Lot <br /> City,State Zip Code Phone Number /q /3 <br /> ,/�_ / /<, Section <br /> A-i t ti �� ��b�D 745--;-‘99,-‘y45- (circle one <br /> /V ti/ Q T Q N; R /7 Eo W <br /> H.Type of But ung(check all that apply) Lot# <br /> 1 Eor 2 Family Dwelling-Number of Bedrooms / / Subdivision Name <br /> o <br /> �_ Block# �l�/!�/L�S //ilJ f r e$ <br /> ❑Public/Commercial-Describe Use -�' <br /> ❑City of .- <br /> O State Owned-Describe Use ail) <br /> / <br /> — Town of N�/0/J <br /> ' <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. 0 New System %RePlacement System 0 Treatment/HoldingTank Replacement Only 0 Other Modification to ExistingSystem(explain) <br /> 1B. 0 Permit Renewal ❑Permit Revision ❑ Change of Plumber 0 Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> KNon-Pressurized In-Ground ❑ Pressurized In-Ground 0 At-Grade ❑ Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑ Holding Tank 0 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 /> ysv - 7 G 1/3 ,SSo 76-a? <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units i ❑ �, <br /> New Tanks Existing Tanks c 2 i �ir. 'a n <br /> Septic or BaldinPante- /06/ /CVO / /e.5�1&r <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 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 <br /> VIII.County/Department Use Only / <br /> Permit Fee Dat ssu ssuin Agent Sign e / <br /> Approved 0 Disapproved $ _" /A in* / <br /> ❑Owner Given Reason for Denial •i/•,��'s• <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> 41 aiSfAt$. -Pawk w`A0 Irc, strkthAcAt sewer., i E C O V E r <br /> fl�.u.vh <br /> 1 r- ,i <br /> Sis�w� est toe s Sof+ ti Ort WvK e� (pieta %'r`r. „ .R. 3 0 2020 <br /> Attach to complete plans for the system and submit to the County o y on paper not less than 8 1/2 x 11 inches in size U <br /> SBD-6398(80313) ! Burnett County <br /> Land Services Department <br />