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`,,IE-lliv County, __.... _ <br /> Safety and Buildings Division 0NrN e, <br /> _ , p 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> R S Madison,WI 53707-7162 A-14-.A _5 G <br /> cC r-rt -5( to-� '5 l 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. /' ft(f e,, <br /> I. Application Information—Please Print All Information v 'TQY,lD:2.30 r <br /> Property Owner's, ttName // Parcel# Q 7e),Y, R. Wi6 ag <br /> L 14/v C.4b/,, S f5 7/ad 0,2.740E <br /> Property Owner's Mailing Address — Property Location <br /> 7 0 33 S �j Pill ti re. r►l to/J� /`p c/1 Govt.Lot <br /> City,State Zip Code Phone Number G �/ /, /, Section o78 <br /> I-�i��k1e� Pm' 5so37 a?/8 370 / 70/ T yi N; R /6(circlEoorii , <br /> II.Type of Building(check all that apply) Lot# <br /> X1 or 2 Family Dwelling—Number of Bedrooms c2 /2s Subdivision Name <br /> Block# Sci le I Nam- .5 O'g <br /> ❑Public/Commercial—Describe Use <br /> 777"' <br /> ❑ City of <br /> 1 CSM Number ❑ Village of <br /> ❑State Owned—Describe Use i <br /> -� Town of .5 GC)/5 5 <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. Flew System , ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> I <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 /> tNon-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> 1 ❑ 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 /> 30 0 , 7 142? Vsro 9'5- <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units h <br /> New Tanks Existing Tanksy o U ). . � wcD a <br /> Septic oraloldiwg-.ank /p o a `- Moe / _r-ti f4 f ftvdo 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 /> VIII.County/Department Use Only <br /> 6 Permit� Fee Date Issued Issuing Agent Signatur <br /> Approved ❑ Disapproved <br /> $ 2 yipiza� <br /> ❑Owner Given Reason for Denial <br /> IIX.Conditions of Approval/Reasons for Disapproval �,, <br /> Ain't- Ca St-'bc c s GC !i 76( q <br /> Fotteci, W covert,-( ond S re Ai it/41 ■ch E C 1 [1 V i <br /> Attach to complete plans for the system and su it to the County only on paper not less than 8 1/2 x 11 i)siz 1.�1 <br /> Firs 0 2 ' 2} <br /> r <br /> Burnett County <br /> SBD-6398(R. 11/11) <br /> Land Services Department <br />