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•c"--� .1-••v? • County <br /> Safety and Buildings Division / #ram e.t <br /> B iJ l 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> -, 'N Pe Madison,WI 53707-7162 � �_3L 40 <br /> F „,,, C51-023.23 <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 <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel#O 7 co64 oZ 38/7 /,Z 3 <br /> ecJ tCi'd,,S S7ron1 0 3 ©oo o/%ooe) jp,QE 7 <br /> Property Owner's Mailing Address Property Location <br /> p <br /> O Sa 6 .414-4)1e-1 .S 7 8 Govt.Lot <br /> City,State Zip Code Phone Number ' /a/ <br /> // ,` s(,J /<,�� /<, Section <br /> SiTe/J w-7- - Y g 7 - .5:4.— P/-7 e O (circle one <br /> II.Type of Building(check all that apply) L Lot# T 30 N; R/ 7 E orb <br /> or 2 Family Dwelling-Number of Bedrooms 3 Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use ❑ City of �— <br /> ---- <br /> CSM Number ❑ Village of <br /> ❑State Owned-Describe Use <br /> Town of /C/MO e-f5 <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' ❑New System [teplacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal 0 Permit Revision ❑ Change of Plumber ❑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 ❑ Pressurized In-Ground ❑At-Grade ❑Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑ Holding Tank 0 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 /> 1sv . 7 Gy3 1573 91'..5 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units a o o <br /> New Tanks Existing Tanks y o 411 P Y . _ <br /> rZ U in yr ia. C7 0. <br /> Septic or Heh ngTank 7Dov r-- /pip f /v o r w e-5 G a 71--- <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) Plumb is Signature MP/MPRS Number Business Phone Number <br /> WADE RUFSHOLM 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 Feeeam Date Issued Issu Age t Si ture <br /> ❑ Owner Given Reason for Denial sq -✓ 5/1/4 3 i <br /> IX.Conditions of Approval/Reas ns for Disapproval <br /> 01E6- .(,1 5e- {oe. -F 5-Alc 74'efi4145 125 clAQ c - W I (e`-I i 1 <br /> -r-- ECEOVED <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x I in.siz(i y 0 1 2023 <br /> SBD-6398(R. 11/11) Burnett County <br /> Land Services Department <br />