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County <br /> Safety and Buildings Division BURNETT <br /> "fir lei 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> 4 ,� f P.O. Box 7162 <br /> Madison,WI 53707-7162 �� <br /> 0 <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 CiWft,G /t2U(C44) <br /> unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are Project Address(if different than mailing address) <br /> submitted to the Department of Safety and Professional Services. Personal information you provide may be <br /> used for secondary purposes in accordance with the Privacy Law,s. 15.04(1)(m),Slats. /-m e— <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name l Parcel# O -7'O e/ <br /> ,4 Z, 4 AA) S O-3- o00 <br /> Property Owner's Ma iling Address Property Location <br /> 16250 _51Y <br /> Govt. Lot <br /> City, State I / r Zip <br /> [Ctoddep�� Phone Number SGJ k, /V[sy,,Section� <br /> �`/g/ �1(O N✓ <br /> WT S /P T" T 3 N; R l (circle ors <br /> II. Type of Building(check all that apply) c� Lot# <br /> Al or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block# <br /> ❑ Public/Commercial-Describe Use El city of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of <br /> Town of j�,c)O a <br /> III. Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. �New System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> Type of POWTS System/Component/Device: (Check all that apply) <br /> Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound > 24 in.of suitable soil 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) Sys7 Elevation <br /> DO / 300 3o d <br /> VI. Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units <br /> New Tana Existing Tanks <br /> in CF -E <br /> U n y m w C7 a, <br /> Septic or ffelA neMk <br /> Dosing Chamber ,A <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Prin t) Plumber's Signa tore MP/MFRS Number Business Phone Number <br /> WADE RUFSHOLM �- I GxG�/V „yam 227691 715-349-7286 <br /> Plumber's Address(Street ,City,State,Zip Code) G r� <br /> PO BOX 514,SIREN,WI 54872 <br /> VW. CountyDepartment Use Ord <br /> Approved Disapproved $Permit Fee Date Issued Issui g t Signature <br /> ❑ Owner Given Reason for Denial 7 y/y4t Zp�3 <br /> IX. Conditions of Approval/Reasons for Disapproval I v =LD <br /> MAY 18 20155 <br /> Al IRN ;01 IPA, <br /> Cc; -IS-q Attach to complete plans for the system and submit to the County only on paper not less than S 112 x 11 inches in size ZONING <br /> SBD-6398(R03/14) <br />