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,,,vf:ry-.,, County <br /> Safety and Buildings Division /� <br /> yi e. <br /> D = 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> Sn Madison,WI 53707-7162 9 _c=2Lf C)4"7 <br /> ,4;..:,.., C' i AL{-- 07 L5%3,3 <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 g•3tiS' ,t kt fr-e,,, <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. /`v <br /> I. Application Information—Please Print All Information ' <br /> Property Owner's Name Parcel# 6 7 p/a, .Z Ve /5—.2 3 S <br /> -1I 6hz e5 e-1 os' oo/ ©f 3eZov <br /> Property Owner's Mailing Address Property Location p 4/ -Fccap*.3b2r7 <br /> �d -5J d 7'/s A L I. Govt.Lot <br /> City,State Zip Code Phone Number y, <br /> h, Section p,2 3 <br /> Gf�Ash/g_5fait) .7-L, d/57/ 3a7 63s 291 sctrcleone <br /> t I' Type of uilding(check all that apply) /� Lot# T yp N; R �S E o�W�' <br /> r 1-or 2 Family Dwelling—Number of Bedrooms �G Subdivision Name <br /> _` Block# <br /> ❑Public/Commercial—Describe Use r.--- ❑ City of ".----- <br /> ❑State Owned—Describe Use �_ CSM Number ❑ Village of �t / r <br /> 2q p� 7 3 'own of .. /�C-kso4- <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> 7 <br /> A. tew System ❑ Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑ Permit Revision 0 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 ❑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 /> 34v , 7 41-2, ysd 9s 5c <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units a 9 b o <br /> New Tanks Existing Tanks o y . A <br /> ) <br /> I Septic or I3eldtng'farfir /QQ v /4°0 / *yT 4/f r,c- T\ <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 Qs Signature' MP/MPRS Number Business Phone Number <br /> WADE RUFSHOLM 'sl y /� 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 <br /> }III.County/Department Use Only <br /> y��,( <br /> Approved ❑ Disapproved Permit Fee Date Isstpd Issuing gent ature <br /> $1126 <br /> I 126)/2t2q <br /> DAV <br /> ❑ Owner Given Reason for Denial � � <br /> IX.Conditions of Approval/Reasons for Disapproval t i 61 b!> cqAc- <br /> i FO1IOw ct Ccwi4-7 aid s�ai1 c ref turu -/-sIECEINED <br /> f Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 1 rim es in JAN 2 6 2024 <br /> Burnett County + <br /> SBD-6398(R. I 1/11) Land Services Department <br />