Laserfiche WebLink
i �r; . <br /> •rKTr�,��., County � <br /> Safety and Buildings Division N �rid <br /> i; 0$ 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> `., n S Madison,WI 53707-7162 :23_%, <br /> ^ �/ 1oLg o fr �•` lid 1 23 O / <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# 0 7 o/R .? VO/5 /y y <br /> i Arr e. ,) 6/ e' , oa o oa ©///oa <br /> Property <br /> Owner's Mailing/Address Property Location /p�,/ <br /> g O S�l C-AA (e-r- R Govt.Lot <br /> City,State Zip Code Phone Number /V d y, SC 1/4, Section // <br /> iI 6 u r(/ Ali, .S y O J c psi 79/ o 73 Z. circle one <br /> II.Type of B rlding(check all that apply) Lot# T �O N; R / E oW <br /> -i,or 2 Family Dwelling-Number of Bedrooms 12 Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use .......- <br /> 0City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of - / <br /> p-Town of ct-A G•�s e),t <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑New System replacement System 0 Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> `` 0 Change of Plumber 0 Permit Transfer to New List Previous Permit Number and Date Issued <br /> B. ❑Permit Renewal ❑ Permit Revision <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 0 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 /> 3c. , 7 17/02y' %so 95%oz <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units U o <br /> New Tanks Existing Tanks 4g, o I' IA A <br /> c U i~n is. 3 a. <br /> Septic or lda -Teak- L O4,j� / o / r u f-/.��.0 e-. <br /> Dosing Chamber / f <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plu er's Signature MP/MPRS Number Business Phone Number <br /> WADE RUFSHOLM 4_ _/ 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> �v« <br /> PO BOX 514,SIREN,WI 54872 <br /> VIII.County/Department Use Only <br /> Approved ❑ Disapproved Permit Fee, Date Issued Is ui g gent rgn re <br /> ❑ Owner Given Reason for Denial $41 Q�' la7/23 <br /> IX.Conditions of Approval/Reasons for Disapproval I <br /> 9A)D cicjois i5-6.4e- nr,,/v.24 <br /> --j 'Ek.. E [IVED <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 a i r 1 es AM 2 6 2023 <br /> jjj <br /> Burnett County <br /> SBD-6398(R. 1 l/11) Land Services Department <br />