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Coun <br /> :.._. Safety and Buildings Division <br /> 1400 E Washington Ave P.O.Box 7162 Sanitary permit Number(to be filled in by Co.) <br /> '•;,1 �"�.! <br /> j c� Madison,WI 53707-7162 <br /> I � <br /> i <br /> Sanituy Permit A.pplicatxon State Transaction Number <br /> In accordance with SPS 383.21(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 32� Lk <br /> purposes in accordance with the Privacy Law,s.15.0 l)m,Stats. <br /> I. Application Information—)Please Print AH Information <br /> Pro erty ner's Name Parcel# p <br /> pa O O <br /> } Property Owner's Mailing Address Property Location PG� <br /> Govt.Lot <br /> City,State 1 lip Code Phone Number Section <br /> /b(circle on <br /> i `�� � 7��`3 T N; R E o +N <br /> i <br /> H.Type of Building(check all that apply) Lot# <br /> or2 Family Dwelling—Number ofBedrooms � Subdivision Name <br /> Block# <br /> Public/Commercial—Describe Use .� ❑ City of <br /> CSM Number ElVillage of 1 0-State Owned—Describe Use <br /> Townof 197e-ye twO <br /> III.Type of]Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ! New System <br /> y � El Replacement System ❑Treatment/Holding Tank Replacement Only El Other Modification to Existing System(explain) <br /> �• u Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> ! Before Expiration Owner <br /> rRITIType of POWTS System/Component/Device: (Check all that apply) <br /> �NlorrPressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> D 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(so Dispersal Area Proposed(so System Elevation <br /> /-/a� -� 96, <br /> W.Tank Info Capacity in Total #of Manufacturer <br /> � Gallons Gallons Units <br /> New Tanks Existing Tanks <br /> I w U fn 4 <br /> Septic or Heidinr'"* <br /> i <br /> Dosing Chamber <br /> i <br /> jYTI.Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plum er's Signature A MPIWRS Number Business Phone Number <br /> WADE RUFSIIOLM � 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 <br /> i <br /> l '' M.Conn /De artment Use Only <br /> i Q Approved ❑Disapproved Termit Fee Date Issued i I e Signature <br /> Q Owner Given Reason for Denial <br /> IX.Conditions of Approval/Reasons for(Disapproval <br /> i <br /> 'in' UP 7091 <br /> l 827 <br /> I <br /> �4zs� <br /> Attach to complete plans for the system and submit to the County only on paper not less than /2 inches m size <br /> SBD-6398(R0313) Burnett County <br /> Land Services Department <br />