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County <br /> Safety and Buildings Division ,C3cj/-,U z <br /> _ 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> P Madison,WI 53707-7162 _22,_t g� <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 /> i 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 /> I the Department of Safety and Professional Servies. Personal information you provide may be used for secondary Q <br /> purposes in accordance with the PrivacyLaw,s. 15.04 1 m Stats. Sib g / ,4rk_5� <br /> 1. Application Information-Please Print All Information <br /> Property O -'s Name I Parcel# p 7 oz sZ, -ve <br /> Awn Gor f5� 3,66 62� 0061 <br /> Property Owner's Mailing Address Property Location <br /> 3 7c, f r, Govt.Lot <br /> City,State Zip Code Phone Number y, 1 l <br /> /<, Section <br /> '� �A /v 5� 4 2 t T (circle one <br /> D� YD N; R E oC <br /> II. ype of Building(checkall that apply) Lot# <br /> or 2 Family Dwelling-Number of Bedrooms _5 ,ta Subdivision Name f Q�,l S<'-NS <br /> Block# <br /> j ❑Public/Commercial-Describe Use ❑City of <br /> I _ <br /> �—State Owned-Describe Use CSM Number El Village of <br /> � <br /> 5kown of Cam/¢ <br /> i <br /> ?II.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A, I ❑New System Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> i <br /> B. ❑ Permit Renewal ElPermit 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 /> y' 61on-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑ 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(so System Flevation <br /> 41so , -2 6 7� dsG-� 9 <br /> VI.rank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units A B o 2 <br /> New Tanks Existing Tanks y o p <br /> i <br /> Septic or i lef4i".5 Tmrk MOO QC�� fj I a(^e•J s�- G <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 turen 227691 Number Business Phone Number <br /> WADE RUFSHOLM //��//���� 227691 715-349-7286 <br /> ��-- <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 <br /> FIII.County/Department Use Only <br /> {(Approved El Disapproved Permit Fee Dr,tf�Is}°;dp Vnent Si u <br /> ❑Owner Given Reason for Denial IA A <br /> IX,Condi °ons pf Approya easons for Disapproval <br /> s Lot ��j/ � <br /> 04 m ce4_ :,4.v59,t 5r4bkc. <br /> - IVe Q44e Yhe `1-k.� Sllee-�-• In AUG 0 <br /> Attach to complete plans for the system and submit to the County only on paper not less than #2xJJinches in size <br /> Burnett County <br /> Land Services Department <br /> SBD-6398(R. 11/1 I) <br />