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o.,, County <br /> Safety and Buildings Division 49 is N <br /> 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> ;, ',; P Madison,WI 53707-7162 514-14-22, e25-0 <br /> cgr-Q2_- ( 48 <br /> { <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 yjoject Addr ss(if different than mailing address) <br /> = the Department of Safety and Professional Servies. Personal information you provide may be used for secondary i > 3 6 .714 <br /> purposes in accordance with the Privacy Law,s. 15.04(l)(m),Stats. <br /> I. Application Information—Please Print All Information Oj!3t%17,iLI a f'1 /¢'G le <br /> Pro r <br /> �aI Vo/Ice (' 1-ty Owner's Name p7=032.?-q(-16-36-S <br /> v 57L 5-00/ -0/0 /70 <br /> { Property Owner's Mailing Address Property Location Pam/ <br /> f 3,2 - 'y074 4-r/e /J). ). Govt.Lot / <br /> City,State Zip Code Phone Number y, /4, Section '3 <br /> Aldc ol)el' M/1J 5-3°r 7e3- 6/ /y9/y �// (circle one <br /> T 7/ N; R /6 E.a <br /> II.Type of Building(check all that apply) Lot# <br /> 07 or?.Family Dwelling—Number of Bedrooms Subdivision Name <br /> Block# —� <br /> U Public/Commercial—Describe Use --� ❑City of <br /> Li CSM Number ❑Village of <br /> State Owned—Describe Use <br /> V O'CI W.3 05own of ✓d J/ice <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicab e) <br /> A' ' [ ,Iew System ❑Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> I-- i List Previous Permit Number and Date Issued <br /> { B. { 0 Permit Renewal ❑ Permit Revision ❑Change of Plumber ❑Permit Transfer to New <br /> Before Expiration Owner <br /> W.Type of POWTS System/Component/Device: (Check all that apply) <br /> DI/Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑ Holding Tank 0 Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) f Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units n L to N c.) <br /> New Tanks Existing Tanks c ;; C y p <br /> Septic or Hektirrg-rnir— I j�0 /(/W / fv0rkL)e.j C� <br /> Dosing Chamber <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 I <br /> /� 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 Date Issued I in Age Signature <br /> Approved ❑ Disapproved $ �_ +�O �O/�LI'�� <br /> Q')(fJ� <br /> I ❑Owner Given Reason for Denial <br /> IX.Conditions of Approval/Re sons for Disa proval <br /> &lnee4- Al( 5e-f bkc�e5 f- fl5�5 Rye �.;iy` Y ' C C Q M G1 4 22zt. k,. UJ <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 n.,11 es in size I , .c LJ <br /> Burnett County <br /> Land Services Department <br /> SBD-6398(R. 1 i/11) <br />