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x County <br /> Safety and Buildings Division �Qy r <br /> p 201 W.Washington Ave., P.O.Box 7162 Sanitary Permit Number(to be fill inb <br /> y a. <br /> P Madison,WI 53707-7162u���a <br /> Sanitary Permit Application 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 Servies. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s.15.04 1 m Slats. b 3 1y n a vas r <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# 0-7 ©j <br /> J <br /> Property <br /> yOwner's Mailing Address 1 Property Location �c <br /> S D fee l ,41V J /�"'1�/e Govt.Lot <br /> City,State Zip Code Phone Number „�,�y, t 4 <br /> / � $� /<, Section ? <br /> 1 f�/v- S3_V17 6/0? �,� (1/l�l�j�' ,(circle one <br /> II. pe of Building(check all that apply) Lot# T 3 N; R l b E <br /> Al or2 Family Dwelling-Number of Bedrooms ASubdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use ❑City of �-- <br /> ❑State Owned-Describe Use CSM Number ❑Village of �- <br /> vi P 17ATown of <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑New System p2r-$eplacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal El Permit Revision El Change of Plumber ❑Permit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS S stem/Corn onent/Device: Check all that apply) <br /> XNon-Pressurized In-Ground ❑ Pressurized In-Ground ❑At-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treat ent Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 3oa /; 6 7- S 2,- <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o o <br /> New Tanks Existing Tanks 0 c Y p <br /> k U. ii� v1 u C7 a <br /> Septic or C/vo - p� <br /> Dosing Chamber OJC-00 <br /> VII.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) a o(¢— <br /> PO BOX 514,SIREN,WI 54872 <br /> VIII.Coun /De artment Use Only <br /> Permit Fee Date Issued I u' <br /> El Owner <br /> S <br /> ❑ ipn <br /> Approved ❑ Disapproved $ �� �� �'��' <br /> Owner Given Reason for Denial <br /> 91 <br /> Ix.Conditions of Approval/Reasons for Disapproval �� <br /> �k 0�}W/V1 i5 qSS-61 �.� A �looc��ki►;rN OcaAe,\c� mostrip <br /> .be. Nr\ COCO-OVr G\�4a.N.on o�C aSS� • (s 9 d E <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 112 x in in <br /> SBD-6398(R. 11/11) Burnett County <br /> Land Services Department <br />