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ti"k i <br /> 4 t , County <br /> Safety and Buildings Division N�'� <br /> ` 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> , Madison,WI 53707-7162 -2,Z- c21, I <br /> State Transaction Number <br /> Sanitary Permit Application <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 mailinaddres) <br /> the Department of Safety and Professional Servies. Personal information you provide may be used for secondary ,/ 7l3��/�-/ A <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. �l/ <br /> I. Application Information-Please Print All Information ' <br /> Property Ovkiner's Name Parcel# Q 7 oa ,39/6 D 9 <br /> 6 /GKSo/t) Ce n,er'c/A/p 4-Lc oY 000 0//0C/ <br /> Property Owner's Mailing Address Property Location ,QC,/ <br /> ,CJ O X 6/V Govt.Lot City.,ty,State Zip Code Phone Number 1,, .&'ZII'/, Section ej <br /> Glee.i5'/e )( t/'�.r 57/s `I 3 577 -253—C T ✓?9 N, R < circle one <br /> E <br /> II.Type of Building(check all that apply) Lot# <br /> i Subdivision Name <br /> i or 2 Family Dwelling-Number of Bedrooms i4/`/Q.g —� <br /> ✓ <br /> _ Block# <br /> ❑Pubic/Commercial-Describe Use <br /> ❑ City of <br /> ....----' CSM Number 0 Village of -_-- <br /> ❑State Owned-Describe Use ��d <br /> 0 Town of /W7e <br /> III.Type of Permit: (Check only one box on Hine A. Complete line B if applicable) <br /> A. to <br /> New System ❑ Replacement System 0 Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> List Previous Permit Number and Date Issued <br /> B. ❑ Permit Renewal ❑ Permit Revision 0 Change of Plumber ❑Permit Transfer to New <br /> Before Expiration Owner <br /> NIV.Type of POWTS System/Component/Device: (Check all that apply) <br /> n-Pressurized In-Ground 0 Pressurized In-Ground ❑At-Grade 0 Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> 0 Holding Tank 0 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(sf) Dispersal Area Proposed(sf) System Elevation <br /> 3o0 , 7 41.2 y Vi'd 96 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units 0 o,, o <br /> -fl U <br /> New Tanks Existing Tanks y o y; E E ( 1 <br /> Septic or iyekdinrilitk /D©p `aPo / /U C r e.J e.s C c) 1 74-- <br /> Dosing Chamber <br /> ' <br /> VII.Responsibility Statement- II,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's ignature MP/MPRS Number Business Phone Number <br /> WADE RL'FSHOLM () 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 <br /> VIII.County/Department Use Only <br /> Permit Fee aa, Date Issue uirg ent Si <br /> X.Approved ! 0 Disapproved $ 1 101,3/22. <br /> i 0 Owner Given Reason for Denial <br /> I ;.. ditio of Approval/Reasons for isapproval <br /> CMee+ ail 5ekbc i 214 El/095� <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 rt x lyiinch ipsixe., . r, ,, <br /> L , <br /> SBD-6398(R. 11/1 H) Burnett County <br /> Land Services Department <br />