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Conti <br /> Safety and Buildings Division , j 4 rN e <br /> lf <br /> ''+' 1400 E Washin ton Ave <br /> I- g Sanitary Permit Number(to be filled in by Co.) <br /> p,., P.C. Box SRIQa0_ <br /> ,277 <br /> Madison,WI 53707-7162 <br /> 64T-aa -a43 <br /> Sanitary Permit Application Sate TansactionNwnber __ <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental / <br /> unit 103 L 433'L/J <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 /> I. Application Information-Please Print All Information .SI./++t- <br /> Property Owner's Name Parcel# O7 6.rr/. D a? VO /4 0 7 <br /> Ad4,n f c , ,6_ 7706 07.51ob <br /> Property Owner's Mailing``Address Property Location 4/r�r f 3 1 <br /> 3 /5- �J� ,pe /..y e n Govt.Lot <br /> City,State Zip Code Phone Number y,, '/, Section 7 <br /> QfaJbgPP 'et 59230 2/2-3yo- '2U (circle on <br /> IL Type of B ding(check all that apply) Lot# T /D N; R/Y E r W <br /> 911 or 2 Family Dwelling-Number of Bedrooms 7d Subdivision Name <br /> Block# 5Prin%(SPeav. A��a V 14 <br /> ❑Public/Commercial-Describe Use ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of � ,/ <br /> --- g Town of _1:-.07 <br /> III.Type off Permit: (Check only one box on line A. Complete line B if applicable) <br /> I <br /> A' 0 New System placement System <br /> 0 Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> S. 0 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 /> re-Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> n 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(se Dispersal Area Proposed(sf) Syst levation <br /> 75-0 , .-7 <br /> /®72 //oO 1 i� �' <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units s v U a <br /> New Tanks Existing Tanks m o g h) ::4, m m <br /> o. U m w h ia. 0 W <br /> Septic or Holding Tank /00 es 4,760 aa66 /ticr&Je.Sed -wc-A -1— -I <br /> Dosing Chamber <br /> VU.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 <br /> (Jack- <br /> /tf I�/ der- 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) •(�- <br /> PO BOX 514,SIREN,WI 54872 <br /> rVAIII.County/Department Use Only <br /> ip,Approved ❑ Disapproved Permit Fee Date Issued Issuing Agent Signature <br /> t <br /> ❑ Owner Given Reason for Denial 37-57— )Z- ' /4. 2z ii A <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Citik 6503 <br /> S 1/2,- <br /> C <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 Int <br /> 11.EIEDVIE <br /> in size <br /> DEC 1 5 2020 <br /> SBD-6398(80313) <br /> t <br /> Burnett County <br /> Land Services Department <br />