|
------- County ----
<br /> i Safety and Buildings Division ,ocf^r1J e-7
<br /> 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be i,". y Co.)
<br /> Madison,WI 53707-7162 g/AN - _ l 8'3
<br /> State Transaction Number
<br /> Sanitary 'Permit Application
<br /> nwesc ance id-3th SPS 383.2 (2),+i'W(is.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 r.aiihag address)
<br /> the Denww ent:of Safety and Professional Series. Personal information you provide may be used for secondary ,2 Act.7 7 ? a r' 4 A LA./imposes in accordance with the Privacy Law,s. 15.04(i)(m),Stats. ,/
<br /> >ppIi^sitioo Information-Please Print ADD iafforrmation
<br /> 'Prcpre. -Owner's Narne Parcel# p 7 0 d S. a 3.3 /`/ /
<br /> Lw...1 _ Qc lL 4 /29� Tries 2) 06 coy a/5'006
<br /> Ptooe�v ,r.e:'s Mailing Address. Property Location Gc/
<br /> 3 G e._Ai€5 e e. c_ Govt.Lot 7
<br /> „.. I Zip Code Phone Number [+�
<br /> /U o 1/.,� R ro0 i-L &c / !o /08 -77T 6E�G/• '�is circl fG
<br /> ., ,.v'+. wi1 ing(e eca all Mat apply) Lot#•iCi o. ._`:'arrii`:f Owa7ltog-Number of Bedrooms
<br /> Subdivision Name
<br /> �"l /
<br /> Block#
<br /> �,L. ,. b.<i/'.,,,m.xe:r cia —DP.scri3-.Use
<br /> ❑City of
<br /> '.....
<br /> -.�
<br /> CSM Number ❑ Village of
<br /> �,S ai.. . :glee.—Describe,Use,
<br /> /�Y ` /p IT /-7 �'Townof_ ,/� e-.L✓ y
<br /> ,yp e ofPerneitx (,iaeeit only one box on line A. Complete line IS if applicable) J
<br /> New i System f ;epiacement System 1 L i Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain)
<br /> �'� List Previous Permit Number and Date iss_;ed
<br /> .r., i'r-,mhf.Renevval =a-mit RevisionI ❑Change of Plumber ❑Permit Transfer to New
<br /> ! ,...Fore Expiration xpiration Owner
<br /> LW,Type of POWTS yystem/Cosnponendt/Device: (Check all that apply)
<br /> &'ion-Pressurized:in-Ground ❑ Pressurized In-Ground ❑At-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soi:
<br /> Hold ins':anti L",'Other Dispersal Component(explain) ❑Pretreatment Device(explain)
<br /> ^V,Dis45e snb T reaknant Area duffer nsatioaa.
<br /> Design Flow(god) ' Design Soil Application Rate(gpdsf) i Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elation
<br /> Capacity in 1 Total #of Manufacturer
<br /> Gallons 1 Gallons Units a' o Q
<br /> New Ta ks E;=stirs Tanks '- o U . , a 0 8 I u,
<br /> • y 5 rtU v� ti .�C7 fi,
<br /> `:'i I,i' espoersibili y Statement- 7,time 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 I lumber
<br /> iV;i3E RUFSHOLM i ��/
<br /> cam+/
<br /> (�/ _ 227691 715-349-77_
<br /> 36
<br /> ='inber's Address(Street,,C!},State,Zip Code)
<br /> PC FOX 5 4.SIREN,WI 54872
<br /> C.ottittrih'eparttnent Use Only
<br /> ,�,,,V f Permit Fee Date Issued I in A nt Sign
<br /> ii=-
<br /> ,i Owneri.en Reason for Denial j S � 5 egad
<br /> IX< 0ood?t ons of A pprovaa/Reasons for iD sappro✓al
<br /> (gee - A..11 5 6ci.c s C C© C� 0MC� --
<br /> D Ctc#l& ,i scar
<br /> _ tub- 0 5 2022
<br /> - Mtech to complete;plans for the system and submit to the County only on paper not less than 8 1 11 es in size
<br /> Burnett County ,
<br /> Land Services Department
<br />
|