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. ' f•,,a County <br /> l '` Safety and Buildings Division liyr,.)e <br /> 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> • P Madison,WI 53707-7162 <br /> State Transaction Number <br /> Sanitary Permit Application <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 �ei8/a se"y-! -4 .�1A <br /> purposes in accordance with the Privacy Law,s. 15.04(l)(m),Stats. 7 <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# 07 O/$ o? ,.9'P/6 ,35$- <br /> ,.Z eff 5h41f=Fe0 /6 S93' o/foots <br /> Property Owner's Mailing Address Property Location Ill/ / <br /> 6/5-5-/.s- s-1.v. 7% <br /> t/�0 //'I� Govt.Lot <br /> City,y,State Zip Code Phone Number Y4, /<, Section `� <br /> (/N e. 4,7, / 1SS0,3� f�i�/ o"y4 ':17 >, (circle one <br /> ,� T 39 N; R /6 E oi <br /> ( IL Type of Building(check all that apply) Lot# <br /> gLor 2 Family Dwelling-Number of Bedrooms / aN;71. 3 Subdivision,/ Name Poyde/•eSR �eSo ' <br /> �, Block# CcvJdo <br /> ❑Public/Commercial-Describe Use ,- <br /> ❑City of <br /> -�----- ❑ Village of <br /> ❑State Owned-Describe Use CSM Number g <br /> Town of_74 e/1'Q/t/ <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. 1 0 New System I.Zeplacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> I <br /> E. 1 ❑ 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 ❑Pressurized In-Ground ❑ At-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> Vrtiolding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design �Flow( I Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> I — <br /> VI.Tank Info Capacity in Total #of Manufacturer I <br /> ( Gallons Gallons Units o •'''' c> <br /> New Tanks Existing Tanks it y bT3 a ro A <br /> U in . v4 Lz. C7 A. <br /> s} e or Holding Tank .4,24 <br /> 4 <br /> d .2O40 / es)/ , 5 T <br /> t 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 Signature MP/MPRS Number Business Phone Number <br /> WADE RUFSHOLM G/'(/ 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 ❑ Disapproved Permit Fee Date Issued I 1 , ent S at e <br /> ❑Owner Given Reason for Denial $37.5LI/ I 3i f <br /> IX.Conditions of Appr val asons for Disapproval LK % ((0391 $'31 <br /> ►'� A' a�� 4 5 k I'C !1 w!tiM G✓1 C I I V <br /> ED <br /> ►1/1 1,(.5 - v✓1 e 4- (4 ^ r tA, (4/40,1,43 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 t 11 :hesAPR in size 10 2023 <br /> Burnett County <br /> SBD-6398(R. 11/11) Land Services Department <br />