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County <br /> "; I! Safety and Buildings Division e <br /> 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> P.O.Box 7162 <br /> �vArJ- �-73 <br /> Madison,WI 53707-7162 <br /> Sanitary Peril Application State TransactionNmnber <br /> n 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 PIP }� <br /> p umoses in accordance with the Privacy Law,s.15.04 1 m,Slats. %�k R D <br /> 1� lication IInformation-3Please]Print All IInformation �! <br /> Property Ors r's Name Parcel#0 -7 O 3 23 <br /> L O <br /> ?:cper'y Ow is Mailing Address Property Location COL i 3t rL <br /> / Govt.Lot <br /> v ty,State Zip Code Phone Number --�c� I'4L) y, nl j %<, Section <br /> (circle one <br /> KJ T N; R jZ_E o SN <br /> JE-'ir ype of 3fb lmling(cheep all that apply) Lot# <br /> or 2 Family ily dwelling-Number of Bedrooms Subdivision Name <br /> Block# <br /> _l Pub;c/Commercial-Describe Use <br /> ❑City of <br /> CSM Number ❑Village of <br /> &atc O n.cd-Describe Use j ) <br /> aTownof Z-., L!C-O/y <br /> UT.Type of]Permit: (Check only one box on line A. Complete line$if applicable) <br /> ! A. i stem AN <br /> New Sy <br /> stem El Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> i <br /> • ❑ Permit Renewal 'Permit Revision ❑ Change of Plumber ❑Permit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> j Before Expiration Owner <br /> I.i,yTe of POIA✓71'S System/Component/Device: (Cheep all that a lolly) <br /> { Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> Holding Tanlc ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(b d) Design Soil Application Ratc(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> VZ <br /> ?.'i a;ek Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o �„ <br /> New Tanks Existing Tanks r. Q <br /> O ° a <br /> i aU in Cl) wC7 a <br /> Septic er i'lele4xkSanl: <br /> 1 nosing Chatnbcr i <br /> ; <br /> { <br /> 11K.Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature/1 MP/MPRS Number Business Phone Number <br /> WADE RUFSI-IOLM � / 227691 715-349-7286 <br /> G <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 <br /> Vrrl.CounCy/De artment Use Only <br /> j >� Permit Fee Date Issued Issuing Agent S' afore <br /> A)proved Disapproved y / / <br /> j LJ Owner Given Reason for Der iai 3�s / ��2/ 4- <br /> Coaam1itioaas of Approval/Reasons for Disapproval y.111. - IS <br /> lr E �.. <br /> T_ APR 19 2021 11 <br /> Alaech to complete plans for the system and submit to the County only on paper not less tha 1/2 X 11 inches in size <br /> 1 <br /> 3 a Z. Burnett Gounty <br /> �..��'�-c398�1Z0�13, i <br /> Land Services Npartti OOt <br />