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$'O S ai s,�r`VrU9 County <br /> Safety and Buildings Division <br /> 1,y*i 1400 E Washin ton Ave <br /> P P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> � � <br /> Madison,WI 53707-7162 <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 Services. Personal information you provide may be used for secondary _ <br /> purposes in accordance with the Privacy Law,s. 15.04(l m,Stats. I/A <br /> I. Application Information-Please Print All Information l <br /> Property Owner's Name Parcel 4 0 7 03 6 ::�, yP/713 <br /> 6pA) B14J`- Sr- S'05- 003 0« w6 <br /> Property Owner's Mailing Address Property Location <br /> 733 e-, RA VIA) 2 �,,rY�/� , Govt.Lot 3 <br /> City,State Zip Code Phone Number y, r/4, Section 1-3 <br /> circle one <br /> H.Type of Building(check all that apply) Lot 4 T N; R E or <br /> or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> _ Block 4 <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of �- <br /> iq Town of 4,0^J1 p rJ <br /> III.Type of Permit: (Check only one bog on line A. Complete line B if applicable) <br /> A. ❑New System ❑Replacement System 7Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑ Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner 158 r <br /> IV.Type of POWTS S stem/Com onent/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.Dis ersaVrreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) 7spersal Area Proposed(sf) System Elevation <br /> ,,�d <br /> VI.Tank Info Capacity in LGiallons <br /> 4 of Manufacturer <br /> Gallons Units v to <br /> New Tanks Existing Tanks y a <br /> rn w V P. <br /> Septic or Hulling Tack /.J-0 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 <br /> �AY 227691 715-349-7286 <br /> � <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 <br /> VIII.Co un /De artment Use Only <br /> Permit Fee Date Issued Issuing t Signature <br /> �pproved ❑ Disapproved $ p% <br /> ❑Owner Given Reason for Denial 3 75"� G-9 r �S <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Ain <br /> EC�ENE <br /> Attach to complete plans for the system and submit to the County only on paper not less es�p slrg 20+5 <br /> JUN 1 <br /> BURNETT COUNTY <br /> ZONING <br />