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`;i.as ,riN� County <br /> Safety and Buildings Division <br /> t D K 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> S P S .. Madison,WI 53707-7162 3 acJ 23—g/ �l� <br /> '' %`r,,,,, , ` -e3 —7 3 <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(I)(m),Stats. <br /> I. Application Information-Please Print All Information L5Q/2 ka)r)6a-c.> C>7 /—L. <br /> Prope Owner's Name Parcel# 1,// <br /> -e-! /f7g, /a /ii�,I ,5 °Parcel <br /> # `��JlD5 U�5 P50 _ <br /> Property 0 lter's Mailing Address Property Location .. goa Z <br /> 3 /7 kLU`J iCJ(.V l_ l/ C l_ Govt.Lot <br /> City,State Zip Code Phone Number I <br /> f� ) (�/l //� / / / ,/r/ IA, /d, Section <br /> �C 0nhfir te_ d�.0 C.&aBi 6Cc i_6 4 dv3 '' ircle one) <br /> T go/o N; R f E or W <br /> II.Type of Building(check all that apply) Lot# <br /> [34I or 2 Family Dwelling-Number of Bedrooms ,--,. 5(.00. <br /> S bdivision Name' / /1 / / <br /> Block# ��/i7No C.� fey7c /*/0 <br /> ❑Public/Commercial Describe Use ..---_ <br /> City o <br /> ❑State Owned-Describe Use CSM Number ❑ Village of <br /> V Town of_-_2_ 50n <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑New System Replacement System ❑ Treatment/HoldingTank Replacement Only ❑ Other Modification to ExistingSystem(explain) <br /> Y � P Y p Y ( P ) <br /> 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 itlil kno yin <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> qNon-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑Mound>24 in.of suitable soil 0 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 /> /l <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units "Ft u o <br /> New Tanks Existing Tanks y c 2 g 8 p 'a 'a <br /> ( c5 c' . 'a' c7 a <br /> Septic or4iotdttIg4-ank 75/') 7hv / l„ ela <br /> Dosing Chamber ( � ✓ /C!(_ <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumbe 's Signature MP/MPRS Number Business Phone Number <br /> G.�WADE RUFSHOLM d'-4- 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 <br /> V�III.County/Department Use Only <br /> ) Approved ❑ Disapproved Permit�e� Date Issued Issuing gent • re <br /> ❑Owner Given Reason for Denial 6/ /�� <br /> IX.Conditions of A proval/Reasons for Disapproval /J <br /> ✓peek A(( 5& ,cG,s -I- t.4t. 7s4JtF413 j 1(.0(463 i �f <br /> [Q5" D Ti JUN 0 6 2023 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 3 1/2 x it iarirciac" <br /> Burnett County <br /> Land Services Department <br /> SBD-6398(R. 11/11) <br />