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Safety and Buildings Division County yrAj-e,7�4_ <br /> 0 s 201 W.Washington Ave., P.O. BOX 7162 Sanitary Permit Number(to be filled in by Co.) <br /> ' p S Madison,WI 53707-7162 �/ <br /> 15C954 <br /> i <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 A ddress(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 /d <br /> Property Owner's Name Parcel# 0 7 QO 52r1714 <br /> c- b—P (' J o J� O 3 00 O <br /> Property Owner's Wailing Address Property Location Pam—In 2 <br /> o?Q y ada /4 ve Govt.Lot •L✓ <br /> City,State Zip Code Phone Number yb �6 may?�� �-� Section <br /> LNG K t �'s' �� �U �..�circle on <br /> N; R <br /> II.Type of Building(check all that apply) Lot# T_.!_� E of <br /> �l,or 2 Family Dwelling-Number of Bedrooms QV7 a Subdivision Name <br /> s <br /> Block# �— <br /> ❑Public/Commercial-Describe Use <br /> � ❑ City of --� <br /> ElState Owned-Describe Use CSM Number ElVillage of <br /> V -?3 1 own of <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.T pe of POWTS System/Component/Device: Check all that a I <br /> ❑Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade fz 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(sf) System Elevation <br /> 3o0 1 30v 300 7 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units fl B o fl 2 <br /> New Tanks Existing Tanks c 6 a <br /> 2 U <br /> Septic or l3ddhr-Dank Q <br /> Dosing Chamber O Q `� S'QQ <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 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) ap�ci <br /> PO BOX 514,SIREN,WI 54872 <br /> VIII.County <br /> /De artment Use Only <br /> Approved ❑ Disapproved Permit Fee Date Issued Issuing Agent Si e <br /> 00- <br /> El Owner Given Reason for Denial LJa� J la s/�3 <br /> 116i <br /> IX.Conditions of Approval/Reas ns for Disapproval <br /> l - <br /> �hee� l� SeI-b�cw5 + <br /> MAY 2 3 2023 <br /> 9nl <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1 'iltl ches in size <br /> Burnett County <br /> VN Land Services Department <br /> SBD-6398(R. 11/11) C�% <br />