Laserfiche WebLink
.`c .K Ir ., / County <br /> Safety and Buildings Division ,�c//'It)27 <br /> U S I 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> P S Madison,WI 53707-7162 � — ill I 01 <br /> '',-., ,, ., .a C� 3"tb. <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 Addres (if different than mailing address) <br /> a ' <br /> the Department of Safety and Professional Servies. Personal information you provide may be used for secondary ,p Kam' <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. FDfi� D� <br /> I. Application Information-Please Print All Information /� <br /> Property Owner's Name Parcel# 0 7 d/%1 .2 y0/5-o <br /> lirlU � /1/ee r ' .5 05- DO/ e ' 0000 <br /> Property Own s Mailing Address Property Location �G n <br /> t '�/a0 <br /> J 5 C AA) A r y W if Govt.Lot <br /> City,State / Zip Code Phone Number /< / <br /> j� 7' `[, // / '/p /<, Section <br /> i I yaSO.) id�f' J 7�` 6 '57 �07 74'—V700 V4 N; R /�circle one <br /> II.Type of Building(check all that apply) Lot# T 7 E o1 <br /> Kor 2 Family Dwelling-Number of Bedrooms 3 — Subdivision Name .....----- <br /> Block# <br /> ❑Public/Commercial-Describe Use —..--- <br /> 0City of <br /> CSM Number ❑Village of <br /> ❑State Owned-Describe Use DrTown of �a GK 5 O/i. <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' 0 New System ;Nteplacement System ❑Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal 0 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) 1 <br /> 4lon-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 /> 4/5--0 , 7 ‘ /.3 6 5 0 7‘,3 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> a, <br /> Gallons Gallons Units t U 9. <br /> y <br /> New Tanks Existing Tanks -' o ;; Y ,�A H <br /> U y Cl) iz C7 c% <br /> Septic or Neldr mdr !�0 D moo / N�'4®7�7'/4-r /r 7� <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) Plum er�ture _ 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 /> VIII.County/Department Use Only <br /> Approved 0 Disapproved PermitFee Date Issue I ui g ent�i�1 e <br /> 0 Owner Given Reason for Denial 4 5 r/7 0(/ C}{o� <br /> IX.Conditions of Approv I/Rea ns for Disapproval C.K.P.✓l a 54?s c,°-3 vie 5-k-le_ /7 ;re/ S C [. �{T3 <br /> AttECIEOVIE <br /> ach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 in:res ize JUL I J L 0 5 2023 J <br /> Burnett County <br /> SBD-6398(R. 11/11) Land Services Department <br />