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County <br /> Safety and Buildings Division ,, /t1 _# <br /> Q 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 /> OF "&43 <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(V 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. f � / InA,,S,A <br /> I. Application Information-Please Print All Information (� <br /> Property Owner's Name Parcel# 6 7 0/ 02 6 /b 5 <br /> G/-e e�_' Ar/S5oJ vs' 005/ oDv <br /> Property Owner's Mailing Address Property Location /O e/ -TQY- <br /> 380 ( 0 /(e r 5 7�i�o,,t iP� Z/ <br /> Gout.Lot Ct35-1 <br /> City,State yL Zip Code Phone Number y,, /,, Section� <br /> eT/���l�eo✓itJ jYJ/1J. ��58�� �/� 3YS� 3G� T .7g N; R�Eoret) <br /> II.Type of Building(check all that apply) Lot# <br /> 4-t-or 2 Family Dwelling-Number of Bedrooms <br /> Subdivision Name <br /> �- Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of <br /> -� Town of <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' ❑New System /'g-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 NV 1-13 <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/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdso Dispersal Area Required(so Dispersal Area Proposed(so System Elevation <br /> 200 / 300 301 1 Y g <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units c <br /> �0 U U42, <br /> U y <br /> New Tanks Existing Tanks v o �v a <br /> U y Cn w C7 0. <br /> Septic or_Woidt gunk 0 2 El <br /> e <br /> Dosing Chamber 6-0&j l .J <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 Feeje Dat Iss eeed�) Issuing Agent Signature <br /> ❑Owner Given Reason for Denial $ q�v _ <br /> IX.Conditions of Approval/Reasons for Disapproval (�M (3 <br /> Pni I A KI 9 1 w9h <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 z iH itr i <br /> Burnett County <br /> SBD-6398(R. 11/i 1) Land Services Department <br />