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County <br /> Safety and Buildings Division pgcNe <br /> 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> Madison,WI 53707-7162 5f I _Ark 4 <br /> �J►i1v �G <br /> (5e5W <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 �i.0 g�v� L.� .5 <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. 6 7 6 <br /> I. Application Information-Please Print All Information <br /> ( Propertyrt Owner's Name , 7� Parcel# © 7 0.3 oZ --1 �/ / 6_SS <br /> l` o c ,c,n, //, s /S `as e./600o <br /> ?roperty Owner's Mailing Address Property Location Tay_ 1 D 2 2-1 32 <br /> Y 7 L: E/der t€r(7 S t Govt.Lot C.City,State Zip Code Phone Number 1/4, /, Section _2 <br /> 0,4 /I i 2 -f o ?7, 3 6 z�ji .3.aI 00 91/ circle ones).--) <br /> q T / N; R �� E or Q/ <br /> Il.Type of Bui3'ding(check all that apply) Lot# <br /> or 2 Family Dwelling-Number of Bedrooms 4/ 4C Subdivision Name <br /> Block# /A /e.KJ A-G.res <br /> ❑ 'ubi is/Commercia -Describe Use ❑ City of <br /> `./ CSM Number ❑Village of <br /> U State Owned-Describe Use '4 <br /> X`fown of W ASS <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑New System %.Replacement System 0 Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> w: <br /> List Previous Permit Number d Date Issued <br /> 3. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber 0 Permit Transfer to New <br /> Before Expiration Owner 2022% 4 122 1191 <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> Non-Pressurized In-Ground 0 Pressurized In-Ground El At-Grade ❑Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> i Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> Y.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 /> boo , 7 8SY 9'Dp /b0 ' ,4 <br /> VI.Tank Info 1 Capacity in Total #of Manufacturer 2. c U <br /> Gallons Gallons Units w 0 r, 6, y <br /> New Tanks Existing Tanks ar o Y = , A A <br /> g c5 in •N ; Lt 0 a. <br /> Septic or Hding Tank -0o gcp0 /360 p� rives <br /> AJdrGD-)-SK�t'`J <br /> Dosing Chamber j J <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 /_ J `/�` 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) lJ <br /> PO BOX 514,SIREN,WI 54872 <br /> VIII.County/Department Use Only <br /> ! Approved i ❑ Disapproved PermitFee Date Issued <br /> j� Issuing Agent Signature <br /> ! j ❑ Owner Given Reason for Denial $ "1`-'6 (9(IF I` DZLI <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> 1( A- c , thb,,.,,k-S D I C C OVE D <br /> Tow a1a .n Ca� iy a1d 540- re <br /> -k /u irc nt/.t+s JUN 17 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 arch n size <br /> Burnett County <br /> Land Services Department <br /> SBD-i6398(R. I I/1 I) it,S75 c,1/4.a RPM <br />