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. �,•asrt�i�:�. County <br /> Safety and Buildings Division <br /> i 0 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> s p s - Madison,WI 53707-7162 -�J�23_ 17 <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. 7 Q oZ Le e <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# p.7 0/? .? 3 9 3 <br /> e- 5-I5- kea 0/8/00 <br /> Property Owner's Mailing Address /� Property Location /0 L �� 0 <br /> 3 <br /> 3D D e e,.e� t P'�/' 43 17 Govt.Lot <br /> City,State Zip Code Phone Number / st '/4, SCE %4, Section 13 <br /> Lr�e e_.+W*eJ lnoi) :55113 7is�77 3.r6� (circle one <br /> II.Type of Building(check all that apply) t� Lot# T 3 9 N; R 6 E or vb <br /> D4-r 2 Family Dwelling-Number of Bedrooms �" 51 / Subdivision Name <br /> i Block# <br /> ❑Public/Commercial-Describe Use -- ❑City of <br /> ❑State Owned-Describe Use CSM Number S 139 El Village of <br /> V a9 to9 f I :Town of /?,) <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. V_New System ❑ Replacement System ❑ Treatment/Holdin Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> Y P Y g P Y g Y ( P ) <br /> B. [I 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 apply) <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) I Dispersal Area Required(so Dispersal Area Proposed(sf) System Elevation <br /> 34 . s xP 600 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o <br /> New Tanks Existing Tanks o <br /> U s cD a. <br /> Septic or HQLdiwg-Tank ,y O O <br /> Dosing Chamber t/ i <br /> I IJ-4 <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/Department Use Only <br /> $(Approved ElDisapproved Pe(r�mi1t Fee� Date Issued <br /> ui , ent <br /> El Owner Given Reason for Denial $ Iv.5 <br /> I.X.Conditions of Approval/Re sons for Disapproval <br /> M eel- a Y 5e &1 � 564e rr.re^4_�; <br /> Pn' <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 112 x 11 in ize <br /> Burnett County <br /> Land Services De artrq M <br /> SBD-6398(R. I I/11) <br />