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`caxnu .:. County <br /> Safety and Buildings Division �NrAi <br /> D s -' 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> `\ P Madison, WI 53707-7162 <br /> •`1 ` -S_. ` Sp�1 r-23 -I`7A. (05L(45� <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. � 9a S/ n%_M Q �1 � O l� <br /> I. Application Information-Please Print All Information /'" 1 LAI <br /> Property Owner's Name Parcel# © 7 0 2 9' a 90 / V o r <br /> t)A4 N S`/-Ga� ic.K 4 -s/S 5^75- o 3s000 <br /> Property Owner's Mailing Address Property Location . /V it <br /> 83/ 6 Po itA, .e_ L- Govt.Lot 4D <br /> City,State Zip Code Phone Number /., 1/4, Section s <br /> .SA A•Kp2 AJ 5537 7 ne <br /> T 4/0 �cucle oV N; R � E or�V <br /> II.Type of Bui ing(check all that apply) Lot# <br /> or 2 Family Dwelling-Number of Bedrooms 7 Subdivision Name <br /> . - <br /> Block# /It/e J ,/l <br /> o Public/Commercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use <br /> `— CSM Number ❑ Village of ' — <br /> Town of S .Oil/ <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. La New System ❑ Replacement System ❑ Treatment/HoldingTank Replacement Only ❑ Other Modification to ExistingSystem(explain)Y P Y P Y ( P ) <br /> B. ❑Permit Renewal ❑ 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 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(gpdst) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> VI.Tank Info Capacity in Total #of : Manufacturer <br /> Gallons Gallons Units o 'd o <br /> New Tanks Existing Tanks c y Y 1i g <br /> 0 <br /> . 0 m cii X, C7 F. <br /> Septioor Holding Tank pr 0,0 D ja0 / Al�eS e r <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) Plumber's 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 /> 'III.County/Department Use Only <br /> Approved ❑ Disapproved Permit Fee Date Issued xi <br /> IX. Issuing ent Signature <br /> m <br /> ❑ Owner Given Reason for Denial $ .)-15� $ 120ed Gt <br /> IX.Conditions of Approval/Reasons for Disapproval e f t 656 t375 <br /> Ateefac,1Se4 1 EC� C OMED <br /> NLa./4 4- kialic it-e€ciA rervLe,11-S <br /> uS-F 1 (Cu✓1 `rt.4Ae444 . �, <br /> 1 h <br /> Attach ,1 omplete plafns for the system an ubmit to the County only on paper not less than 8 1/2 x 11 inc es ni lsiee I �s j 1 8 2fl23 <br /> tl. Burnett County <br /> SBD-6398(R. 11/11) ` Land Services Department <br />