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County <br /> Safety and Buildings Division <br /> D 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 /> 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 � �D-lL�Z38� ��2�2�_ <br /> u oses in accordance with the PrivacyLaw,s. 15.04 1 m,Slats. //� 2 <br /> I. Application Information-Please Print All Information 6 4 i Sa <br /> Property Owner's Name t / Parcel# 0 7 p 3 y 37/ -TA <br /> Property Owner's Mailing Address Property Location <br /> c <br /> e0 r /Tv Govt.Lot <br /> City,State Zip Code Phone Number , <br /> (f �f /., /,, Section Y-21 <br /> Gr,+a fsv Nr �ic�� 's/ /� cucle one <br /> II.Type of Building(check all that apply) Lot# T 7 N; R E ott <br /> $4 or 2 Family Dwelling-Number of Bedrooms 5— Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of Yao p /o/ $Town of .!yam r,4 e— L,4ke__, <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 A 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 /> . 00 1 02 gal-,5, 1 a ,S <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units <br /> eC <br /> New Tanks Existing Tanks <br /> U v� W A w C7 G <br /> Septic or Holding Tank '10 D DO� <br /> Dosing Chamber 600 <br /> ✓ O <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) <br /> PO BOX 514,SIREN,WI 54872 <br /> VIII.County/De artment Use Only <br /> Approved ❑ Disapproved Permit Fee gDate Issued Is i A nt Si atu <br /> ❑ Owner Given Reason for Denial $ 115 1�/✓43 <br /> IX.Conditions of Approval/Reas ns for Disapproval /7 <br /> Mee4 all Se&,;s 54=4< r .'MOVA D v <br /> n I SEP 14 2023 <br /> Attach to complete plans for the system and submit to the County only on paper not les than S lin x 11 inches in size <br /> Burnett County <br /> Land Services Department <br /> SBD-6398(R. I I/I I) t-. I <br />