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,, .,;,; County <br /> Safety and Buildings Division AN r n} e <br /> tt S 201 W.Washington Ave., P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> `\ r Madison,WI 53707-7162 5 Ft A - . - 13t <br /> • _ i`1. itil,wi CST aa- 1O6 <br /> Sanitary Peiiriit 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. 3g ( 06 <br /> I. Application Information—Please Print All Information // <br /> Property Owner's N e Parcel#p .7 6/y vZ 3$i. 5 <br /> Ac./1)4-/ 4" <br /> ,,,? U5' e//COCA <br /> Property Owner's Mailing Address p Property Location <br /> b 5 07 kcs'�.r(/i9'"f/O/t) /1 Govt.Lot <br /> City,State ( Zip Code Phone Number ,/4 AU L) , <br /> /o <br /> i �© r �� II L, (�/O sb`0 �. / SLc) , , Section J. <br /> 1! b' . 7/- T 3� N; R /`5,.circleE one <br /> II.Type of Building(check all that apply) Lot# <br /> ��//'' 3 Subdivision Name <br /> or 2 Family Dwelling—Number of Bedrooms /_ <br /> �— Block# <br /> ❑Public/Commercial—Describe Use ❑City of <br /> CSM Number ❑ Village of '.--. <br /> ❑State Owned—Describe Use ,v /� /// yL� <br /> �— Town of h4co e- <br /> HI.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' ❑New System replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> i I <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> j Before Expiration Owner <br /> IV.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 /> ❑ 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 /> Y,57) / 7 6'3 65?) 73—5-- <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units a o ° <br /> New Tanks Existing Tanks t 0 y Y p cc <br /> rt U ii ti v C7 0. <br /> Septic or 1.14,14irretratz /pd v / / /oarcde_..j �n <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 —/r " 227691 715 349 7286 <br /> Plumber's Address(Street,City,State,Zip Code) f <br /> PO BOX 514,SIREN,WI 54872 <br /> VIII.County/Department Use Only <br /> Permitrm Fee Date Issued ILX. <br /> ing in1 <br /> 1 Xpproved 0 Disapproved <br /> ; ❑ Owner Given Reason for Denial $ `? b1?3I22" <br /> IX.Conditions of Approval/Re sons fqr Disapproval <br /> ,Mel all 5G' (.i��I_J r 1 (0 )op <br /> a�ac 2 2022 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8r1/2 x 111...fj.12 <br /> IBurnett County <br /> Land Services Department <br /> S.BD-6398(R. i l/11) <br />