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I.. .P•rtri:;:�.r., County <br /> Safety and Buildings Division <br /> 1400 E Washington Ave Sanitary { yCo.) <br /> _ •. ,.,�; ..I^,� Sani Permit Number to be filled in b Co. <br /> j P.O.Box 7162 ,^�,,l— 2/_295- <br /> Madison,WI 53707-7162 `'n'v <br /> Kermit Application <br /> Sanitary State Transaction Number <br /> In accordance with SPS 38321(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 subnutted to Project Address(if different than mailing address) <br /> jthe Department of Safety and Professional Services. Personal information you provide may be used for secondary 38�� S / <br /> purposes in accordance with the PrivacyLaw,s.15.04 1 m,Stats. h6 J-e PO/ <br /> I I. Application Information-Please]Print All Information - <br /> Property Owner's NaPe-de- <br /> Parcel#0-7 0 <br /> r'Se.c) Sos oo cs /�©ate 60 <br /> Proper y Owner's Mailing Address Property Location AG <br /> Iti f- /��- ��' ` Govt.Lot <br /> j City,State Zip Code Phone Number /4 /., Section 3� <br /> 6J 1/t�f� rn �-��</3 9 vcle on <br /> t ! T��N; R��E o W <br /> I II.Type off Building(check all that apply) � Lot# <br /> 1 or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> 1 Block# <br /> i ❑Public/Commercial-Describe Use �— <br /> —"' ❑City of <br /> t <br /> 0-1S ate Owned-Describe Use CSM Number ❑Village of ` <br /> KTownof <br /> III.Type of]Permit: (Check only one box on line A. Complete line 1B if applicable) <br /> ? A. <br /> ❑New System replacement System ❑Treatment0olding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> I � <br /> i List Previous Permit Number and Date Issued <br /> B- ❑ Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New <br /> Before Expiration Owner <br /> RV.T32e of P'OWTS System/Component/Device: (Check all that apply) <br /> 1 ❑Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> 91-Hoiding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> 17.IDis ersal/Treatment Area Information: <br /> { Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> 11I.Tank Hnfo Capacity in Total #of Manufacturer <br /> i Gallons Gallons Units <br /> I New Tanks Existing Tanks 2 n <br /> -SeprlM Holding Tank 16 C)6 o?46D o2 Lei/ 5�� <br /> Dosing Chamber <br /> i <br /> VII.Responsibility Statement- 1,the undersigned,assume responsibility for installation of the PONM shown on the attached plans. <br /> j Plumber's Name(Print) PI ber's Signature MP/MPRS Number Business Phone Number <br /> IYA.DE RUFSHOLM 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 <br /> F7Ii[I.Coun /lDe artment Use Only <br /> Approved ❑ Disapproved Permit Fee � Date Issued Issuin A nt Si e <br /> ❑Owner Given Reason for Denial $ 375 13 V <br /> Imo.Conditions of Appaoval/Reasons for Disapproval IE M <br /> i � L V <br /> )S c,c <br /> Attach to complete plans For the system and submit to the County only on paper not less than 812 x n in A <br /> SB+D-6398(R0313) Burnett County <br /> Land Services Department <br />