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1?: •., Count <br /> Safety and Buildings Division i8c,I PA)e: <br /> j� 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> P.O.Box 7162 S�N_�1_ 345 ‘�10(083 <br /> Madison,WI 53707-7162 <br /> . _. .._;;; c5 a1 -a73 <br /> Sanitary �yerrnit 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 Addre (if different t an an address) <br /> the Department of Safety and Professional Services. Personal information you provide may be used for secondary -T-• <br /> Purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. <br /> E. ApplicationIInfformation-P➢easePrintAllIInformation <br /> Property Owner's Name Parcel# 0 7 cp a 9/4)/d if <br /> $71- M e..• )5 ) 4-r",n5- LL., c ,i"' 0 s` 003 0'/t6 acD ►3I0 <br /> ProperlyOwner's Mailing Address / Property Location <br /> ///77 'GG `4 4-/t) /`A-/ Govt.Lot <br /> City,State /� Zip Code Phone Number y, 'A, Section I/ <br /> M�/e l9ib c,e. M' ,7 <br /> , .5 36 7 T / N; R /Zuc E on+hJ <br /> III.:t Type of Building(check all that apply) Lot# <br /> i . i or 2 Family Dwelling-Number of Bedrooms — Subdivision Name <br /> ---Block# <br /> !Public/Commercial-Describe Use ❑City of ,--- <br /> State Owned-Describe Use CSM Number ❑ Village of <br /> T own of ©A K IA-furl <br /> LIII.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> fA. ew System ❑ Replacement System ❑Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> 1 <br /> ❑ Chan e of Plumber List Previous Permit Number and Date issued <br /> RD i ❑ Permit Renewal ❑ Permit Revision g ❑Permit Transfer to New <br /> Before Expiration Owner <br /> 1V.Type of IFOWTS Systenn/Component/]Elevice: (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 soil <br /> 0 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(se System Elevation <br /> 4/5-6 i _7 4/3 & 5.6 73 s <br /> .Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units .n to ,b, 0 <br /> New Tanks Existing Tanks in <br /> o 2L .a.65 2 <br /> a <br /> J ,U in V co 'GE'C., P <br /> Septic or <br /> iiekliag3xnk l t )e)� 7S / "Li el (-1 Pi s c-" >I--- <br /> Dosing Chamber <br /> WI.Responsibility Statement- II,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 J 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 <br /> WEL County/Department Use Only <br /> Approved ❑Disapproved Permit Fee ex, Date IssuedU I A t Si e <br /> i ❑ Owner Given Reason for Denial $ 4 1{I 1 1 2/ <br /> IX.Conditions of Approval/Reasons for Disapproval 1 /U 1a� <br /> 1D � <br /> Attach to complete plans for the system and submit to the County only on paper not less than I r2 x inch-NOVA 18 2021 <br /> SBD-6398(R0313) _ <br /> Burnett County <br /> Land Services Department <br />