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__-- -----____ County
<br /> Safety and Buildings Division , r e9 /`,p,,1 `
<br /> 201 N.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to br 1!._ ,Co.;;
<br /> Madison,WI 53707-7162 5N1-9.' 1
<br /> _-_____- ^_ State Transaction Number
<br /> `, .,a rLi tary Fermi� Application
<br /> ::scoort..1ance with SP8 383.2 (2),Wis.Adm.Code,submission of this form to the appropriate governmental unit
<br /> is required 3r0r to obtaining a sanitary permit. Note:Application forms for state-owned POWTS are submitted to Project Address(if different than rnafi g address)
<br /> the Deoartmerd of Safety and Professional Ser/les. Personal information you provide may be used for secondary
<br /> urooscs in accordance with the Privacy Law,s. 15.04(1)(m),Stets. � /� j t
<br /> App ioetion��nformation-Please Print All Information /�.J/7 .,L ..
<br /> :Pope,Owner's Name Parcel# a '7 (5,;Z 6 me Sig / /`.
<br /> _. ..._._r_ Arc) ,£ a S't>e' n f 4 cTc
<br /> . o'w:t,/ il:ing Address Property Location ,
<br /> y‘Lf� ___GA-J'YI e. s rr- / Govt.Lot pZ
<br /> III Zip Code Phone Number /t
<br /> M./dide r/ 37A' 7Y) it) 1 1.)-'i�3 7.5 3_' 7/V 67,' T 7 o N; R /7 'rci _,
<br /> f,. Building(cheer all that apply) Lot#
<br /> i,,,Dwelling-Number of Bedrooms / Subdivision Name
<br /> _ Block#
<br /> biin/.:...,.......,....-Describe Use
<br /> -- — ❑City of ...-------
<br /> Li:::ate rric�.-Describe Use
<br /> CSM Number / d0 Village of
<br /> V y/ 3< C �t Town of -5 �1
<br /> 2.Type o'Per n it: (Check only one hex on line A. Complete line B if applicable)
<br /> "' ^ New'systemeplacement System 1 U Treatment/Holding Tank Replacement Only ❑Other Modification to Existing Sysi er;explain)
<br /> 1
<br /> —^- List Previous Permit Number any_i-ua a:s ved
<br /> ;emir:Renewal 0 =ermitt Revision Li Change of Plumber ❑Permit Transfer to New
<br /> ,e occ Expiration Owner
<br /> `,1, "iy e o't POWTS SysteeiCumnponent/Device: (Check all that apply)
<br /> '*-on-Pressu;i ed In-Ground ❑ Pressurized in-Ground ❑At-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable sot
<br /> 'Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain)
<br /> V.;is,pe s?..1, r eatment Area ffnfornnation
<br /> Design Flow(gild) ',, Design Soil Application Rate(gpdsf) i Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation
<br /> 3--- 7 1 zei3 er e, 95: 3
<br /> �:. .,,; 1 Capacity in 1 Total #of Manufacturer
<br /> Gallons Gallons Units p v U I
<br /> New Tacks sang Tanks I 0 2 1 c4 o
<br /> 1 ctU rn � � i;r6 F
<br /> Se0c,ar ;_. l006 (QD j Act rtt)C 5C eD i mil'
<br /> as ax; .na Cer i
<br /> `iii•.,i espansi'bility Statement- 11,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans.
<br /> Plumber's Name(Print) ! Plural er's Signatur MP/MPRS Number Business Phone Number
<br /> Vii,,DE RUFSi:OLM ? 227691 715-349-7286
<br /> l__>:nL-er's Address(Street,City,State,Zip Code)
<br /> 'O BOX 5'Ll.,SIREN,154F872
<br /> Via Couad`tyiii2epartrnent Use Only
<br /> + n I PE3Ti3it FEE „^0 Date Issued I i Ag nt Signatu
<br /> ,s'^2?'v;r'df_' ,._.` Disapproved r V
<br /> m �1?5 8//ued ill Owner Giver:Reason for DEniai 1 u
<br /> �.`:i"�nS r. F p,prP,T9Jal 7 esiso uer Disapproval R `�'�a �._.._.
<br /> o� rite �'� beQ64�A� yet 9sQS IECEOVE )
<br /> .1UL 2 9 2022
<br /> �
<br /> Attsc to complete Mans ffor else system anal submit to the County only on paper not less than S 1/2 x 11in sa e
<br /> Burnett County
<br /> SB - , /:
<br /> > .:ti ..•y.. ? Land Services Department
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