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County ) <br /> Safety and Buildings Division 4y,^/ €.-1/— <br /> Z <br /> 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> \ Madison,WI 53707-7162Utki, - 2,- 1.V.2 / 434t5 <br /> n !„2.2-7..3 <br /> { Sanitary Peiiiiit 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 <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. p p <br /> I. Application Information—Please Print All Information • AL U 3 L-K /) <br /> Property Owner's Name l Parcel# e9-7 O 32 2 y/ /5 0 7 3 <br /> !\ yy-A) z /itJ5 ®y c9ad a//c c) <br /> Pr't)opetty Owner's Mailing Address Property Location <br /> li 77/0 '3e)/es 5 A-U — Govt.Lot <br /> City,State Zip Code Phone Number ,5-L y, w %<, Section 7 <br /> inArii e..Ai IkOG(-- W 5 V 75 Co 7✓S 595' v 37 5' / circle oneL <br /> H.Type of Building(check all that apply) Lot# T N; R %-S E o <br /> T or 2 Family Dwelling—Number of Bedrooms <br /> a — Subdivision Name <br /> Block# <br /> ❑Public/Commercial—Describe Use <br /> ❑City of <br /> ❑State Owned—Describe Use —' CSM Number ❑ Village of —"-- <br /> t <br /> Town of SGc//.5$ <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. New System ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to ExistingSystem(explain) <br /> Y P Y g P Y ( P ) <br /> B. ❑Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑Permit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> i <br /> IV.Type of POWTS System/Component/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.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> I 3ov / 36,0 3e' r /oo,a <br /> VI.Tank Info Capacity in Total #of ' Manufacturer <br /> Gallons Gallons Units p ° o <br /> New Tanks Existing Tanks o Y .0 m v, <br /> a. U v) m t% C7 Ci <br /> Septic or 1-Iotttttirran O/.f7 e7 SW / <br /> Dosing Chamber <br /> ��J 0 0 6r7�a .�fe, xJ <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 () ;94 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 ❑Disapproved Permit Fee O Date Issued Issuing Age Sign <br /> ❑Owner Given Reason for Denial <br /> at.S �. 5/31/13d <br /> IX.Conditions of Ap roval/Rea ons foj�Diisapproval /t Alt;.(_:‘, <br /> '�C J�3 �/� <br /> e2� AI f LDS (! t <br /> E )Attach to complete plans for the system and submit to the County only on paper not less than 8 in\11 t hes N44 2 6 2022 <br /> I <br /> SBD-6398(R. l l/11) Burnett County <br /> Land Services Department <br />