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County <br /> Safety and Buildings Division <br /> p _ 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> S P S Madison,WI 53707-7162 Jft I`J a3 <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 1 m,Stats. <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# 0 7 0/ <br /> L6 fep? csG�i�ord 7:�r/ 6.;-25-OoO ak-. r <br /> Property Owner's Mailing Address Property Location <br /> Govt.Lot <br /> City,State Zip Code Phone Number <br /> PP} /<, /<, Section <br /> 6�1- �� j 7 3 .���s 74 kcle on <br /> II.Type of B ilding(check all that apply) Lot# T—�N; R / E o> <br /> 9i"r 2 Family Dwelling-Number of Bedrooms ` 5- Subdivision Name <br /> � Block# �6V�� rimer �0 V' <br /> ElPublic/Commercial-Describe Use <br /> -� ❑City of <br /> El State Number El Village of <br /> State Owned-Describe Use � <br /> V-,Town of <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' ❑New System J�-Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner I M L <br /> IV.Type of POWTS System/Component/Device: Check all that appi <br /> Non-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/Treat ent Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispe al Area Proposed(sf) System Elevation <br /> Vim- 6Y �; 4 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units A o <br /> R1 V U <br /> New Tanks Existing Tanks c ;? B a <br /> cC U y rs c7 a <br /> Septic or Helding_Tjnk /POO <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 St ature 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/De artment Use Only <br /> Approved El Disapproved Permit FeeRM <br /> � DateIssued Vnj, ' a re <br /> ❑ Owner Given Reason for Denial <br /> $ �5 10/03 <br /> IX.Conditions of Approval/Reasons for Disapproval rya S <br /> Fctc�rw <br /> LJ <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 1 �cltln s <br /> Burnett County <br /> SBD-6398(R. I 1/11) Land Services Department <br />