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,, „\; County <br /> Safety and Buildings Division County/1 <br /> rit)e- <br /> 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> ~� Madison,WI 53707-7162 SRN as-1 <br /> C.91"- �.�-77 b 3 99 <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),Stats. <br /> I. Application Information—Please Print All Information • <br /> Property Owner's Name Parcel# 0 7 G/2 vz 4/O /6 as <br /> fj- )-fh p ,Jy F. , - IS— 70 7 _7Ces c) <br /> Property Owner's Maili Address Property Location <br /> v y 9 Y s e <br /> ;/✓er /J r(2 7'ru•y Govt.Lot <br /> City.State Zip Coded Phone Number �< <br /> fit)e.bSi-t'1' W T- yg93 5-'7 - a77- .;- . _ Section <br /> Ccircle one <br /> II.Type of Building(check all that apply) Lot# T 'VC' N; R % E o W <br /> 1-or 2 Family Dwelling—Number of Bedrooms .3 3 CD Subdivision Name f <br /> .------ Block# 5i/Z-rc-'-'' /6)i cc.4 AV, 7o V!" <br /> ❑Public/Commercial—Describe Use - <br /> i ❑ City of <br /> CSM Number ❑ Village of <br /> ❑State Owned—Describe Use —t <br /> 'own of v om,9C/C5''Li <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' 0 New System Replacement System 0 Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> g ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> B. 0 Permit Renewal 0 Permit Revision 0 Change of Plumber <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> ( .Non-Pressurized In-Ground 0 Pressurized In-Ground 0 At-Grade 0 Mound>24 in.of suitable soil 0 Mound<24 in.of suitable soil <br /> 0 Holding Tank 0 Other Dispersal Component(explain) 0 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 /> y50 - 7 9 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units 2 o ° <br /> New Tanks Existing Tanks v o .o ro A <br /> y� Me.) e r rt U C D w c7 w <br /> Septic or Ffeiding�art(i--, /(/'®O / ,t r�e 5 C- c..J <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 /_ 1 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) ��O <br /> 1 PO BOX 514,SIREN,WI 54872 <br /> i <br /> E VIII.County/Department Use Only <br /> Approved I ❑Disapproved Permit Fee iv Date Issued Is uin A nt Sign r' , <br /> ❑Owner Given Reason for Denial $�2`'--- / <br /> 6 r;/O"a J <br /> • <br /> IX.Conditions of Approval/Reasons for isapproval # 1 � iSt <br /> ,meek- 4.(1 S �S ll�J <br /> A a <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 r/2 x 1 i rch in s4A`( 3 1 2022 ' j' <br /> Burnett County 1 v <br /> SBD-6398(R. 11/11) _ Land Services Department <br />