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County <br /> Safety and Buildings Division /10 q2.I <br /> Q _ 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> P Madison,WI 53707-7162 <br /> Spr <br /> , r <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 /> u oses in accordance with the Privacy Law,s. 15.04(1)(m,Stats. <br /> f. A lication Information-Please Print All Information <br /> Property Owner's Name Parcel# A d <br /> Properly Owner's Mailing Address Property Location <br /> L-skit- ad-JAY Govt.Lot <br /> City,State Zip Code Phone Number y, /4, Section 7 <br /> A 1 1 K f y�3 0 (circle o <br /> i II.Type of uilding(check all that apply) Lot# <br /> T _N; R _E o W <br /> i-or 2 Family Dwelling-Number of Bedrooms 9 Subdivision Name <br /> Block# <br /> L!Public/Commercial-Describe Use `— ✓ <br /> � ❑ City of <br /> ❑ CSM Number El Village of <br /> State Owned-Describe Use <br /> f Town of S C D <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑New System I 4MIacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑ Permit Revision El Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner 2 5 wo S <br /> .T e of POWTS System/Component/Device: Check all that apply) <br /> j Y,.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(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> i <br /> VI.Tank Info Capacity in Total #of Manufacturer � <br /> Gallons Gallons Units 2 `y <br /> 9 o U <br /> New Tanks Existing Tanks A " y N <br /> I <br /> c� U rn y cn w 0 a <br /> r Y <br /> R Septic or Holding Tank <br /> Dosing Chamber c 0 I] ,:5-Zx) <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the At ed plans. <br /> i Plumber's Name(Print) Plumb is Signature F22p7'691 <br /> PRS Number Business Phone Number <br /> 1 WADE RUFSHOLM 715-349-7286 <br /> 4 <br /> Plumbers Address(Street,City,State,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 <br /> VIII.County/Department Use Only <br /> Permit Fee Dat Issued Issuin Agent Signature, <br /> Approved I ❑ Disapproved $�-1,5 Cp /�I=q <br /> Owner Given Reason for Denial <br /> I I%.Conditions of Approval/Reasons for Disapproval D <br /> �S <br /> rvlbA) all cw.+y aid �- ,����re►ne nos J2; r Zo�-t J U N t 12024 <br /> IS wnb' ca �► rvla <br /> Attach to complete plans for the system and submit to the unty only on paper not less than S it2 x 11 in es in size Burnett County <br /> Land Services Department <br /> SBD-6398(R. 1 i/11) -$3 17/D l As-(J 41[G pd 33 <br />