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",i County <br /> Safety and Buildings Division be/r/oL <br /> ' 0 s _ .1201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Numbe (to be filled in by Co.) <br /> l Madison,WI 53707-7162 'rW`aa - I 19 lot 1�g4►b2 <br /> :J. <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 purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. 0 q7 V/0/ �/� <br /> I. Application Information-Please Print All Information /2/>a4r�c'�.v-1 f6P' <br /> Property Owner's Name i Parcel# 0 7 0/$ vZ 37 /‘. 3 9 5 <br /> Property Owner's Mailing Address Property Location <br /> 6 4 -S ‘ Govt.Lot <br /> City,State Zip Code Phone Number y, /, Section <br /> 5 f-e..t.) td. ' Yr7a2 �'/9---,lb— 7 g (circle one) <br /> i 3Y <br /> II.Type of Building(check all that apply) Lot# T 3�f N; R `te, E or� <br /> or 2 Family Dwelling-Number of Bedrooms .--3 a 3 Subdivision Name y a <br /> QQ/no 'c/ ,�'c`J <br /> Block# ,+$5 e3So%S /1/41'.1 4.s2 <br /> ❑Public/Commercial-Describe Use ~— <br /> -,... ❑ City of <br /> CSM Number 0 Village of <br /> ❑State Owned-Describe Use <br /> ,�,� 4 Town of /71 ee iu el <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 /> B. 0 Permit Renewal 0 Permit Revision 0 Change of Plumber 0 Permit Transfer to New List Previous Permit Number and Date Issued <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 /> El 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 /> Vs a ` 7 i. .65t ,Z <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units p 0 o <br /> New Tanks Existing Tanks o u Y o <br /> ,, g rt L) v) w a.C7 <br /> Septic or Held aHk /- 60 6 s____ /Doe) / /1 cy 0 C-C.�(fS e Q <br /> Dosing Chamber / <br /> VIY.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signatur MP/MPRS Number Business Phone Number <br /> WADE RUFSHOLM ( ,r / � I` 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) (/✓ /�`� �._. <br /> PO BOX 514,SIREN,WI 54872 <br /> VIII.County/Department Use Only , <br /> Approved 1 0 Disapproved Permit Fee Date Issued I wing ent Sign. .r� / <br /> has7/ii/0 Owner Given Reason for Denial ,„ •`,, / <br /> IX.Conditions of Approv 1/Reasons for tsapproval <br /> •�'E © l El '[ <br /> meek c ( -f c ` 'it s t <br /> JUL 1 1 2022 J <br /> Attach to complete plans for the system and submit to the County only on paper not less tha i 8 1/2 • in size 4 <br /> Burnett County <br /> Land Services Department <br /> SBD-6398(R. 11/11) <br />