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County <br /> l Safety and Buildings Division ef ar/v e- <br /> _ 201 W.Washington Ave., P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> , Madison,WI 53707-71622 <br /> 03459 <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 govemmental 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 34.3 ,-/ ied <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. /J <br /> i I. Application Information-Please Print All Information ' <br /> Property Owner's Name Parcel# © 7 042 y ,A 3 9/Y Y e V <br /> j .o ff. &/CJ4 ? o3 00 0 of/oo0 <br /> Property Owner's Mailing Address / �Q Property Location/eC/ <br /> I`7 S-3.- OA-k PA-I-[ r 1 0 Govt.Lot <br /> City,State r ZipCode Phone Number , 3 e) <br /> _ // �$�✓ /o,S /4, Section <br /> �('Ov�--�/C�t� Gc�� .53�y.- V/ 3�3 / t7 (�(circle on <br /> II.Type of Building(check all that apply) Lot# T N; R f E o <br /> X1 or 2 Family Dwelling-Number of Bedrooms e / Subdivision Name <br /> Block# <br /> 0 Public/Commercial-Describe Use ❑ City of <br /> { 0 State Owned-Describe Use CSM Number ❑ Village of <br /> — )Town of R use <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. 1 Atew System ❑ Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> I B. 0 Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑Permit Transfer to New <br /> 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 ❑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(st) Dispersal Area Proposed(sf) System Elevation <br /> 440 Y.s-S 97. '0 9,( <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o C U <br /> New Tanks Existing Tanks ' o a ra ps <br /> Septic or' t an / 25 2 __ 4.75 e, / / i,-.5 e. 7 <br /> Dosing Chamber <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 Signatu MP/MPRS Number Business Phone Number <br /> i WADE RUFSHOLM f / 227691 715-349-7286 <br /> �j(/ <br /> { Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 <br /> VIII.County/Department Use Only <br /> IrrApproved ❑Disapproved Perm' Fee l Date Issued Iss 'n Age ;Sign <br /> ❑ Owner Given Reason for Denial * 5/5/"] <br /> IX.Conditions of Approval/Reason for D' approval <br /> ite€�- at 5e4-Lc5 j, - D ReEavE,T)\--- <br /> , <br /> 1 Cam!1 <br /> �'has F MAY 3 2022 ' U, <br /> _ l <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 la x 11 Inches In size <br /> Burnett County <br /> Land Services Department <br /> SBD-6398(R. 11/11) <br />