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Comb, <br /> Koa,-. Safety and Buildings Division <br /> r t ; s µ 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> P P.O. Box 7162 <br /> 3 t $ <br /> 401 Madison,WI 53707-7162 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 38321(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 O S 5- <br /> p oses in accordance with the PrivacyLaw,s.15.04(1)(m),Stats. d/��� j G� <br /> L Application Information-Please Print All Information rl l <br /> Property Owner's Name f Parcel# p 7 p/pZ ,2 VtP / <br /> re 4. 1 s /5' 70 o X7000 <br /> Property O er's Mailing Address Property Location <br /> 3 y y 7 r s r Govt Lot <br /> City,State Zip Code Phone Number 13 <br /> ,CgirAoj4Q v0e.r /nrl, 5530 763 , yid�36z D / �, Section <br /> cle on <br /> H.Type of Building(check all that apply) Lot# T N, R / E w <br /> I or 2 Family Dwelling-Number of Bedrooms 2 ` 7 ' Subdivisio Name <br /> 11PublidBlock#Commercial-Describe Use 11 ❑ City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of �t- <br /> XTown of <br /> III.Type of Permit (Check only one box on line A. Complete line B if applicable) <br /> A. ❑New System El Replacement System XTrcatment/Holding Tapir Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> SIV.T of POWTS System/Component/Device. Check all that a 1 <br /> 400-Pressurized In-Ground El Pressurized In-Crround ElAt-Grade El Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> (❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dis ersaVTreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sd) Dispersal Area Proposed(sf) System Elevation <br /> 3Dv <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units ' . U d v <br /> New Talcs Existing Tanks w c v = y <br /> a U fn q � is C7 a. <br /> Septic or Ts ank ©Q O Q O/-4c/e S CCD <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 MPIMPRS Number Business Phone Number <br /> WADE RUFSHOLM , / it 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) �rG� <br /> PO BOX 514,SIREN,WI 54872 <br /> VIII.CountyADepartment Use Only <br /> El <br /> Permit Fee5 Q Date Issued Issuing Agent S <br /> $ ignature <br /> Approved DQ <br /> ❑ Owner Given Reason for Denial O J ✓ r/(X <br /> blun <br /> IX.Coaditioa of APlrrornVn..for Disalrlrroval <br /> ECEIVE <br /> Attach to complete plans for the system and submit to the County only on paper not less than 812 x inc in,AW J—-M <br /> -DD-- <br /> BURNETT COUNTY <br /> ZONING <br />