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.'''!'''ir;,:;. County <br /> Safety and Buildings Division 5 Nr N <br /> ;'�' ' ,�. 'T` 1400 E Washington Ave <br /> � �� .� I_:' 9 Sanitary Permit Number(to be filled in by Co.) <br /> „ S. P.O.Box 7162 G..rN ,- .o _Zig <br /> L, Madison,WI 53707-7162 �1' 431 3� <br /> State Transaction Number <br /> Sanitary Permit Application <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 <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. <br /> I. Application Information-Please Print All Information <br /> Prop <br /> pQ y Owner's Name Parcel# O 0.So7 0'1 y/>6 �y S <br /> dX .4Jf v'-/-,'1/' - ) I. <br /> 0.3— O0Y L3/a©DD 22272- <br /> Property Owner's Mailing Address f Property Location,p Lr/ <br /> a q 6a s A'�� 4 4-k Govt.Lot y <br /> City,State Zip Code Phone Number /, <br /> /a <br /> 7 , Section 33 <br /> "�� (( <br /> ,4�16 N IUll (A). -- 5-5/S circle one <br /> i T V/ N; R to E orb <br /> H.Type of Bunging(check all that apply) Lot# <br /> SC -..1 or 2 Family Dwelling-Number of BedroomsSubdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use — ❑ City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of <br /> -- - TATown of ...Sui 1-51.5 <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> 0 New System Replacement System 0 Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑ 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 /> Non-Pressurized In-Ground 0 Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil 0 Mound<24 in.of suitable soil <br /> n Holding Tank 0 Other Dispersal Component(explain) 0 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 /> ysa , 7 6 V3 6 se 9.3 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units ai o'3 0 <br /> New Tanks Existing Tanks g g 2 t) a <br /> a. U in y oa w C7 Z. a, <br /> Septic or iial. nic /a p /DOD J rtJB r 44)e....5 L. Q <br /> Dosing Chamber <br /> VIII.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 /> VIIII.County/Department Use Only <br /> Approved ❑ Disapproved Permit Fec Date Issued Issuing Agent Signature <br /> $ 2.0 4). � <br /> l/ <br /> ❑Owner Given Reason for Denial 3 75: pz I . /7. <br /> • �'• l <br /> IX.Conditions of Approval/Reasons for I isapproval / /5�3 $3/5 Lb <br /> T,/il ,ti 7i--//- ni_ <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x IItiECEOWIE ) <br /> sin '171:C 6 2020 <br /> SBD-6398(R0313) L <br /> Burnett County <br /> Land Services Department <br />