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Safety and Buildings Division 4Counyr�t3� <br /> _ <br /> 0 S _ 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> ti P S Madison,WI 53707-7162 fr„ <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 Slats. Q <br /> I. Application Information—Please Print All Information r—Ai <br /> Property Owner's Name Parcel# p 7 O/S,oZ o 7 <br /> R otelr_� 1Q ey )4-,) 02 moo o e <br /> Property Owner's�� 1 Mailing Address Property Location Pc-/ -0 11311 <br /> o A)d S`� Govt.Lot <br /> City,State Zip Code Phone Number , 7 <br /> A�/<, $ /., Section <br /> Pf �V n 3 ��/� '{ 02 7 / (circle one <br /> II.Type of Building(check all that apply) Lot# J T �N; R �b E o W <br /> �6­1 or 2 Family Dwelling—Number of Bedrooms Subdivision Name <br /> Block# <br /> ElPublic/Commercial—Describe Use <br /> ❑ City of <br /> ❑State Owned—Describe Use <br /> CSM Number ❑ Village of <br /> KTown of /f 91EP�/t�0 <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑New System .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 <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.Dis ersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o 7� <br /> New Tanks Existing Tanks o v a <br /> U n w 0 G.. <br /> Septic or Holding Tank !�v 2 0 <br /> Dosing Chamber 7j 0 Q <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 /_ f 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 ❑ Disapproved Permit Feed Date Issued I i g ,gent <br /> El Owner Given Reason for Denial $ �5� <br /> IX.Conditions of Approval/! ;sons or Disapproval <br /> 5e-I- c� <br /> SEP 15 2023 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x Ili ches in size Burnett County <br /> Land Services Department <br /> #SBD-6398(R. 11/11) /�5 <br />