Laserfiche WebLink
County <br /> _ Safety and Buildings Division County/1 <br /> r'it <br /> u 1 t <br /> Y p •_ 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> •ti p ' Madison,WI 53707-7162 fit,,, t.21/ p 41 <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 -j-C1. .t P 2 2 9-('7 <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. c. Ai‘"y <br /> I. Application Information-Please Print All Information <br /> Property Owner' Name Parcel# d7 a3, .2 y/ /s /y <br /> G.An)0I-a- c 6,'"3 c /s oV3 02/°' <br /> Property Owner's Mailing Address Property Location <br /> { <br /> `f D 3 3 Gave r rn e.1J AV Govt.Lot <br /> City,State Zip Code Phonene Numberr7 q-7 IA,, 1/4, Section / <br /> f f/,l k./��/I n it) .��0 7 it 1O 1 /d / /U y T 5// N R IsicirclE <br /> el <br /> on <br /> II.Type of Buildin (check all that apply) Lot# <br /> or 2 Family Dwelling-Number of Bedrooms 4— / / Subdivision Name /, <br /> Block# 214--5.5 L.i4 1`.e- Ores <br /> _ <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> ------ CSM Number ❑ Village of <br /> ❑State Owned-Describe Use e <br /> ,.Town of $W/S 5 <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. I i .41ew System I ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> i <br /> ❑ CI Permit Transfer to New List Previous Permit Number and Date Issued <br /> B. ❑ Permit Renewal ❑ Permit Revision Change of Plumber <br /> Before Expiration i 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) i Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 300 l . 7 q.77 y-571 95 . 0 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units 9 g U CO <br /> I New Tanks Existing Tanks y o Y Y a <br /> Septic or Heidi riMk `poo / i 0 / /t)a ri✓e5 G p +— <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' Signatu a 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 ❑ Disapproved Permit Fee Date Issued IssuingAgentt Signature <br /> 00 <br /> ❑ Owner Given Reason for Denial $ /�� S I1 l 2azy . <br /> IX.Conditions of Approval/Reasons for Disapproval f.Kam � 7_- / cF' <br /> net ale Se ac k-s 7 ECENED <br /> Follow u u ca vrl y airy s-f -c r q <br /> ui fe-+rrerrfs <br /> MAY 16 2024 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 ash in size <br /> Burnett County <br /> Land Services Department <br /> SBD-6398(R. 11/11) <br />