Laserfiche WebLink
County <br /> Safety and Buildings Division ,el i"rt l-�'. <br /> 201 W.Washington Ave., P.O.Box 7162Sanitary (toby Co.)9 Permit Number be filled in <br /> Madison,WI 53707-7162Pv ,o -7�Q <br /> !610,5 <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 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),Stats. ,. 2 6%Cf 44121 Sec. <br /> I. Application Information—Please Print All Information ' <br /> Property Owner's Name Parcel# E7? 0 50'.,7 ,..? 35' `b'3Y 5"' <br /> M iGh e_./'e.i )9,4Al -5 C°-/ i 6 ?76 c3v274fe?C3' <br /> Property Owner's Mailing Address i Property Location <br /> s y60 V yTo,ve r5; j h il e Govt.Lot <br /> — --City,State t I Zip Code Phone Number y,, A, Section 3V <br /> ..;5 4 it) i /11/�' 1 .J 5-‘) `f v 7‘.3 3 7i5 5 33_ (circle one <br /> IL Type of Building(check all that apply) Lot# T .3 N; R %5-) E.ID <br /> Xl-or 2 Family Dwelling—Number of Bedrooms ''' ' / 7 Subdivision Name <br /> ii-ii�_ Block# �/LJS©,�C)� �ri•rt.,/ <br /> c/ <br /> ❑Public/Commercial—Describe Use �_ <br /> --� ❑ City of <br /> ❑State Owned—Describe Use CSM Number ❑ Village of �� <br /> ,RTown of Z---/4)0 d,0 ,e,,,..,C /- <br /> i <br /> Hi.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' ❑New System Re lacement System <br /> y � p y ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> ❑ Change of Plumber List Previous Permit Number and Date Issued <br /> B. 0 Permit Renewal ❑Permit Revision ❑Permit Transfer to New <br /> { f Before Expiration Owner <br /> V.Type of POWTS System/Component/Device: (Check all that apply) <br /> ❑Non-Pressurized In-Ground ❑Pressurized In-Ground ❑ At-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> AHolding Tank ❑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 /> by <br /> VI.Tank Info ? Capacity in Total #of Manufacturer <br /> n Gallons Gallons Units t, v ,�, I N <br /> New Tanks Existing Tanks o 0 2 p 2 <br /> atU ci ti wC7 G% <br /> Septic or Holding Tank �_;�' -�L_ I <br /> �oo 0 v?avv / �;t1«-... <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 �! / 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) C� <br /> PO BOX 514,SIREN,WI 54872 <br /> �VIIII.County/Department Use Only <br /> 1^t Approved ! ❑ Disapproved Permit Fee Date Issued Is uin Ag t Signatu <br /> Re <br /> ❑ Owner Given Reason for Denial 5 9 6(/ <br /> IX.Conditions of Ap roval/Reaso s for isapproval <br /> 10EOWIE -0 <br /> CAttach to complete plans for the system and submit to the County only on paper not less than 8 Iinx 1es in ? j h �3�22 <br /> ,)c_f 1 J G LL , <br /> SBD-6398(R. 11/11) Burnett County <br /> Land Services Department <br />