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County <br /> Safety and Buildings Division G3 el/'n, (= _ <br /> _1' D 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> ' ;,,Sp Madison,WI 53707-7162 <br /> 1l IT� �`.2�.' 15� <br /> I-T t0��06� <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 1 ( TD <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. L� /�µr L Q <br /> I. Application Information-Please Print All Information • /C "ICf <br /> Property Owner's Name Parcel# c -7 O/2 ,, S/o /5•2.y <br /> CA/,1l 57 git)r,/iS4 0S VO i 0,'/AoG <br /> � 7 Property /'^ Owwnt?r's Mailing Address , Property Location ,O c_/ <br /> .J 2 Go/fv j"E.',-C) /6/ A) Govt.Lot <br /> City,State r Zip Code Phone Number / y, /,, Section „R�It �}I�' j� J1� -� s1 vZ 6s 4) 7 7 74 3 f S(circle on <br /> T y(i N; R E° W <br /> II.Type of Building(check all that apply) Lot# <br /> or 2 Family Dwelling-Number of Bedrooms / Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use _- <br /> ❑City of <br /> ❑State Owned-Describe Use �, CSM Number ❑ Village of —/, <br /> 1I V/6P CIS ❑Town of 07 (-.loci/-) <br /> HI.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. $New System 0 Replacement System 0 Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. Er List Previous Permit Number and Date Issued <br /> l Permit Renewal ❑ Permit Revision ❑Change of Plumber ❑Permit Transfer to New <br /> . Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> don-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/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation. <br /> 34"0 I , -7 %,-9 '- c-) T <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o <br /> New Tanks Existing Tanks 4 47. <br /> L.o 0, C Y a , <br /> Septic or Tank /000 z--- /E'OJ / /110 r eA)eSC_Gi <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 Signatur MP/MPRS Number Business Phone Number <br /> WADE RUFSHOLM /1 ,I 10-,-` 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 /> l Permit Fee Date Issued in Ag t Signa <br /> Approved ❑ Disapproved $��� /A/I� I�� <br /> ❑Owner Given Reason for Denial <br /> IX.Conditions of Approval/R sons f r Disapproval►M 5�4 5 CI <br /> JUL 1 1 2022 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 i rx 11 indies in size <br /> Burnett County <br /> Land Services Department <br /> SBD-6398(R. l l/l l) <br />