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oty:ursly)r Count ' /L� <br /> y�, <br /> Safety and Buildings Division ' e-- <br /> p s , 'J i 1400 E Washington Ave sanitary Permit Number(to be filled in by Co.) <br /> 'i p F.O.Box 7162 ).1 ,�-/77 <br /> '. Madison,WI 53707-7162 <br /> -,' csr-aro -45 7 <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 02333/ <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 77 5--- <br /> purposes <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. ��'L� L� Lie kJ <br /> I. Application Information-Please Print All Information h /� <br /> Property Owner's Name Parcel# ei 7 c /5 oZ_57/6 %02 <br /> p414 / /,4 y 9 / 61 a c c r'//eoc2 <br /> Property Owner's Mailing A'/ess Property Location I' Uv <br /> t t?O Q <br /> P0 L C3/ d2/Cr Govt.Lot a7 <br /> City,� State./ Zip Code <br /> Phone Numbecr� e/ �) y, �l %. Section /� <br /> ae,t,:S er E.-Li-i- 3 y/ 3 Y/3 �D/ �39 (circle one <br /> IL Type of Building(check all that apply) Lot# T `, N; R / E o <br /> F-1 or 2 Family Dwelling-Number of Bedrooms 2 ✓ Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> 0 City of <br /> CSM Number ❑ Village of <br /> ❑State Owned-Describe Use <br /> Town of /I')..e- 6.01---) <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. i,New System 0 Replacement System yp y 0 Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal 0 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 /> Non-Pressurized In-Ground 0 Pressurized In-Ground ❑ At-Grade 0 Mound>24 in.of suitable soil 0 Mound<24 in.of suitable soil <br /> ❑ 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 /> ,3 �> �� �t5.c-) '15' Y <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units a ° c ,b, <br /> At U v i. m <br /> New Tanks Existing Tanks ii c g y n m <br /> y� a U in . rn w C7 a <br /> Septic or HoldittgTenk /eel() de) /(�j� �e rt (5 C. C7 7`.-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 Signaturer) MP/MPRS Number Business Phone Number <br /> WADE RUFSHOLMG 11 ' /�. r...--_ 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) Cu'� <br /> PO BOX 514,SIREN,WI 54872 <br /> VIII.County/Department Use Only <br /> Permit Fee Date ssue suing7wl4/ <br /> ent Signature / <br /> 'Approved 0 Disapproved $ D O❑ Owner Given Reason for Denial $A8 2 ?� _ <br /> IX.Conditions of Approval/Reasons for Disapproval %�`r' J/ 4/4,5" <br /> at Dra.i4cid Auto tot. lit• D E © N , <br /> it)re cld worst IX, 4 641 � o PIT:4ee et Welt <br /> 1 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2: ni '� in/slid V 1 7 2323 __)/ <br /> —/ <br /> SBD-6398(R0313) Burnett County <br /> Land Services Department <br />