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county <br /> Safety and Buildings Division <br /> w'' 1400 E Washington Ave <br /> ant Permit Number(to be filled 1®by Co.� <br /> ., , L , ^'i P.O.Box 7162 �. (p <br /> Madison,W 153707-7162 ems. - 209 <br /> Sans Permit ApplicahOn State Transaction Number <br /> In accordance with SPS 383.2I(2),Wis.Adm.Code,submission of this:Form to the appropriate governmental unit <br /> ?012) -0$2�02106-(1 <br /> is required prior to obtaining a sanitary permit. Note:Application forms for state-owned POWTS are submitted to Project Address if different than mailin addr ss) <br /> the;Department of Safety and Professional Services. Personal information you provide may be used for secondary f <br /> urposes in accordance with the Privacy Law,s.15.0 1 m,Stats. / 1 <br /> I. Application Information—Please Print All Information /d ©GtJ/V Property Owner's Name / Parcel#417 0/9 02 Jr <br /> p <br /> i Property Owner's Mailing Address Property Location <br /> I L/5 Govt.Lot <br /> 1 City,State <br /> ihpptr Zip Code Phone Number / %<, Section <br /> /C i V fI l e �{) �� �A 4 „ (circle one),,, <br /> ..T'ype of Bu' ing(check all that apply) Lot# T�N; R��_E o N <br /> 11i or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> 7 L <br /> Block# 6-1114197 <br /> j Public/Commercial-Describe Use <br /> ❑City of <br /> j CSM Number ❑Village of <br /> State Owned-Describe Use <br /> i <br /> 59 Town of <br /> { f.Type of(Permit: (Check only one box on line A. Complete line B if appUcable) <br /> A. Q New System Re lacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> Y � P Y g eP Y g Y ' ( P ) <br /> List Previous Permit Number and Date Issued <br /> !m- ❑ Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Pemrit Transfer to New <br /> Before Expiration Owner <br /> T• Type off 1P®W'S System/Component/Device: Check all that apply) <br /> 10 Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑Mound>24 in.of suitable soil )Kmound<24 in.of suitable soil <br /> Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> W.JDis ersal/Treatment Area Information: <br /> Des- Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> Y-L Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units <br /> iNew Tanks Existing Tanks <br /> l a U co) w to <br /> Septic or Weidi"S-Tmk n AM <br /> Hosing Chamber �/� t? � <br /> i CJ <br /> i <br /> jrIIL 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) (f�✓ <br /> PO BOX 514,SIREN,WI 54872 <br /> VF .Conn /Il➢e artment Use Only <br /> Permit Fee (� Date Issued I Ag t Sign <br /> f ❑Approved ❑Disapproved $4 Q �'' ) <br /> f ❑Owner Given Reason for Denial <br /> IX.Conditions of Approval/Reasons for Disapproval M <br /> /0 <br /> ' V <br /> D <br /> Attach to complete plans for the system and submit to the County only on paper not leas than 8 1/2 x t size <br /> S3a-6398(Rfl313) Burnett County <br /> Land Servicos Dtl artment <br /> GI( ISM <br /> S LiZSQ-0- <br />