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: H „r County A <br /> ! ' <br /> ,,. <br /> Safety and Buildings Division y c ie e <br /> "` 0 T 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> Sp S 1f' Madison,WI 53707-7162 _23 _ / <br /> 4� b60 5 3 <br /> 'f4,,`,,,.,4 toVJ (;a'�-.23 -(aI 9 <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 a 6 3.2 <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. ���' � �oa�✓ /S <br /> I. Application Information-Please Print All Information �s <br /> Property <br /> y Owner's Name Parcel# 07 OR y 02 Y9 /4//s 5'f�/000A- /)e-rr y 05". oo/ O eoc'd <br /> Property Owner's Mailing Address�/ / Property Location p / X( l y5 Lig I <br /> 4 I 4 c J•f' 1 <br /> 3.s �y Govt.Lot <br /> City,State r / Zip Code Phone Number y, /., Section /$ <br /> 5�/ C4/eid /i'/ S.Sa 8'd 763--zg- 6 2G a (circle one <br /> II.Type of Building(check all that apply) Lot# T �9 N; R /Y E o <br /> Aor 2 Family Dwelling-Number of Bedrooms 3 Subdivision Name <br /> ----- Block#r <br /> ❑Public/Commercial-Describe Use ❑ City of '__.- <br /> '-.- <br /> CSM Number ❑Village of <br /> ❑State Owned-Describe Use ,-.,[ p i <br /> OcTown of /)Ns'\ <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. +New System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑ 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 /> ❑ 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/Sa , 7 6 5'.3 65 o 95%.5-- <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units oo d 0 <br /> New Tanks Existing Tanks y a g <br /> o C <br /> cC (..) in . v) w c7 a <br /> Septic or Heldg'`F�itrk /O O 0 — MOO / " In)f::/71/- 4'/L .r i 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 (/C/�/ _0�/-- <br /> 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 /> Zi <br /> Approved ❑ Disapproved Permit Fee� Date Issued V3 Is i A nt Si <br /> ❑Owner Given Reason for Denial Y'd)'5 / <br /> IX.Conditigqns of ATprovalfReasops for Disapproval 46" t-14?i-liiliiff <br /> INIP a U S GtltiS -E-Sink r'r i'e /► 1 C E fl E <br /> ll <br /> MAY 2 5 2023 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 in x 1 c in size <br /> Burnett County <br /> Land Services Department <br /> SBD-6398(R. 11/11) <br />