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County <br /> Safety and Buildings Division ,3(4eij <br /> 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> Madison,WI 53707-7162 SFtN--424 <br /> —IT, <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 oZ 713r <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. / <br /> . Application information-Please Print All Information e 5 4 7u/ <br /> Property Owner's Name Parcel#Q 7 0/so a 37 IS 0 2 <br /> Sol SN ole. • S /S /36 0/700e, <br /> Property Owner's Mailing/?tleress Property Location r n v I D 126 31 <br /> P. a40,K 5/�.� Govt.Lot V f� <br /> I Zip Code Phone Number / y, VI, Section ..2�Jebsfe.e ttxr 3 6"73 612 963 Hai. T 39' N; R /icirclEooni6 <br /> O y e;,f Building(check all that apply) Lot# <br /> n <br /> or 2 Family Dwelling-Number of Bedrooms .i Subdivision Name <br /> / 0 ,,Name <br /> J <br /> !� Block# 00 f r,S 6r/1, C <br /> ❑Public/Commercial-Describe Use ❑ City of — <br /> ../---' CSM Number ❑ Village of ' <br /> 0 State Owned-Describe Use Town of I,1 e /V d <br /> :,i.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> New System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> 3. Permit Renewal i ❑ Permit Revision ❑ Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> N.Type of POWTS System/Component/Device: (Check all that apply) <br /> Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> 7Holding 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 /> L-o <br /> 'r:.TanInfo E Capacity in Total #of Manufacturer <br /> i Gallons Gallons Units ,o o ,9 <br /> 1 V U N d v' <br /> I New Tanks Existing Tanks t o i ; a c° <br /> at U i i . v) is.cD o. <br /> i <br /> Septic or Holding Tank -71 <br /> 9000 <br /> D D O AAA.) , ev/e.5 -e-r <br /> Dosing Chamber <br /> ii.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> ?lumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> WADE RUFSHOLM /- r 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PC BOX 514,SIREN,WI 54872 <br /> VIII.County/Department Use Only <br /> Permit Fee Date Issued Issuing Agent Signature <br /> Approved i ❑ Disapproved $ 3-1500 ii <br /> /202'-! <br /> j ❑Owner Given Reason for Denial <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> mee+ CiV Se.4420, S Is �I L (�_m <br /> re a1r <br /> �l LD w cut c�-r� aid S�� Q In (---- �{{ <br /> c cvi�d Gl 17�1 �\': AUG0 9 2024 i <br /> f-1-OldLi n) 4r l� -b complete �'J <br /> Attach to plans for the system and submit to the County on on paper not less than 8 1/a x 11 i4ties in A <br /> u t' <br /> Burnett County <br /> Land Services Department <br /> ,it 316 dita- l�o Z <br />