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Coup <br /> j -'"r'•;•-- .is , <br /> ;;� <br /> Safety and Buildings Division �►`,� <br /> j := 1400 E Washington Ave <br /> y}, 9t Sanitary Permit Number(to be filled in by Co.) <br /> P.O.Box7162 �( '��, / <br /> Madison,WI 53707-7162 Y <br /> SaDituy Permit Application StateTratlsactionN ber <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit O 5 Z)d Z 6 <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 /> ilie Department of Safety and Professional Services. Personal information you provide may be used for secondary / /AOw } Q <br /> Purposes in accordance with the PrivacyLaw,s.15.04 1 m,Stats. G y[4 3 In O iL1 /� <br /> I. H Iitation Infformation-]Please Print All Information SS5RI <br /> iProperty Owner's Name Parcel#C1-7 p 05 2 3 q 1.6 <br /> Property Owner's Mailing Address �) Property Location�p e/ <br /> } 3 7r'3 A,'/� �'` / GovL Lot f� <br /> City,State Zip Code Phone Number y, %., Section-4 6 <br /> /t}M L R-Ite /n 4) 5-S3o<( 6/Z,-Sol—� 74 7 (circle one <br /> T—7 N; R E ore <br /> R.Type of IBuDding(check A that apply) � Lot# <br /> �\or 2 Family Dwelling-Number of Bedrooms J j Subdivision Name <br /> Block# L*�_ A17, Lillie Plwt e s <br /> j Fnblic/Commercial-Describe Use <br /> ❑City of <br /> l - ❑State Owned-Describe Use CSM Number Village of <br /> L �� <br /> Town of /n O <br /> i <br /> HI.Type of]Permit: (Check only one box on line A. Complete line B if applicable) <br /> 1 A. <br /> I )(New System ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing SySiem(explain) <br /> i T1- ❑ Permit Renewal ❑Permit Revision List Previous Permit Number and Date Issued <br /> ❑Change of Plumber ❑Permit Transfer to New <br /> Before Expiration Owner <br /> 1:7:.iype of POWTS System/Component/Device: (Check all that apply) <br /> Noa-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑Mound>24 in.of suitable soil 19 Mound<24 in.of suitable soil <br /> I Holding"rank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gild) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> FYI.'yank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units a o <br /> New Tanks Existing Tanks ;: y i a <br /> j wU �n 2 m AA a <br /> Septic or Holding-Tank l <br /> Dosing Chamber O <br /> 1 C !/ <br /> 1 rIIL Responsibility Statement-1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signat MP/MPRS Number Business Phone Number <br /> 'MADE RUFSHOLM /� �� 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 <br /> I <br /> i 'YTJH.Cowen /De artment Use Only <br /> Permit Fee Date Issued =* !ge#SiWgna5,,/ <br /> Approved El Disapproved $3?S 6" <br /> ❑Owner Given Reason for Denial <br /> Imo.Conditions of Approval/Reasons for(Disapproval <br /> 1�i IJ� <br /> l <br /> Attach to complete plans for the system and submit to the County only on paper not less thaw 12 t I in <br /> i <br /> - i <br /> S3. D-6398(R0313) <br /> Burnett County <br /> Land Services Department I <br /> �K 1 SSv , <br />