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County <br /> , <br /> Safety and Buildings DivisionCA] <br /> ? 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> P.O.Box 7162 <br /> Madison,WI 53707-7162 <br /> _ - State Transaction Number Sanitary Permit Application <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit <br /> s rewired 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 �� / ` _� p <br /> purposes in accordance with the Privac Law,s.15.04(i)m,Stats. J�,fly <br /> R. Application Information—]Please Print All Information <br /> i Pro erty Orw�nelr's ame Parcel#Q `7 C3 .5 <br /> Property Owner's Mailing Ad ss Property Location <br /> N C <br /> i 5 5 r i A KILL c3 J/� , Govt.Lot _5 <br /> i City,State Zip Code Phone Number /A � <br /> /<, Section <br /> A) 9/7 45 ,T/i� (circle one <br /> RII.Type of Building(check all that apply) Lot# T�N' R�E o>� <br /> or 2 Family Dwelling—Number of Bedrooms a Subdivision Name <br /> Block# <br /> Public/Commercial-Describe Use <br /> ---� ❑City of <br /> ❑State Ovned-Describe Use J' CSM Number El Village of <br /> t/ f 3 `Town of �'I e- eJ <br /> Y / <br /> j 111.Type of Permit: (Check only one boss on line A. Complete line B if applicable) <br /> I ❑New System �"�Leplacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> } <br /> i <br /> Permit Renewal El Permit Revision ❑Change of Plumber ❑Pe rmit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration O wner <br /> TV.Type of POWTS System/Component/Device: (Check all that appw <br /> �lon--Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> J Folding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> 1 <br /> VJ Dispersal/Treatment Area Information: <br /> Desi Flow(gpd) Design Soil Ap lication Rate(gpdsf) Dispersal Area Required(s0 Dispersal.Area Proposed(sf) System Elevation <br /> «R.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units Z o 2 <br /> New Tanks Existing Tanks o v a <br /> i <br /> Septic or F mg ank4 , 1 <br /> Dosi ng Chamber C/Vj,C/ v <br /> � 6 <br /> NIIIR.Responsibility Statement- G,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 /> I Wp E RUFSHOLM _ / / 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX 514,SIREN,W1 54872 <br /> 1 <br /> VIIIi .Conn /IIDe artment Use Only <br /> i&I Approved El Disapproved Permit Fee Date Issued Iss ' ee t Si �* <br /> f ❑Owner Given Reason for Denial ✓' s' <br /> Rai.Conditions of Approval/Reasons for Disapproval 00 <br /> qECC0MIE <br /> nIt <br /> Attach to complete plans for�systumit to the County only on paper not less than 8 It, t es i <br /> SBD-6398(R0313) <br /> L,io,.�\ Burnett County <br /> �'/ Land Services Department <br />