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County .��� <br /> Safety and Buildings Division 0 r`tu C: / <br /> 201 W.Washington Ave., P.O. BOX 7162 Sanitary Permit Number(to be filled in by Co.) <br /> Madison,WI 53707-7162 JA <br /> 1 <br /> Sanitary Permit Application State Transaction Number <br /> i 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 /> i the Department of Safety and Professional Servies. Personal information you provide may be used for secondary <br /> 2urposes in accordance with the Privacy Law,s. 15.04 I m,Stats. <br /> y. Application Information-Please Print All Information <br /> j P-operty Owner's Name Parcel# 07 p <br /> P-�am-..�- Le•w� 5 a o2 oeo ©//000 <br /> ?rc•per y C T.er' Mailing Address Property Location <br /> 0?0 8 9 o Al A,0 � �,� Govt.Lot <br /> State qq Zip Code Phone Number N 6) y,,/V hJ /4, Section <br /> 3V.5 <br /> � circle one <br /> T 3/ N; R7 E <br /> .T ype o£Building(checkall that apply) Lot# <br /> o:2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block# <br /> l Public/Commercia;-Describe Use ❑City of <br /> CSM Number ❑Village of <br /> `{State Owned-Describe Use i /,- <br /> tkown of f43 <br /> iAL Type of hermit: (Check only one box on line A. Complete line B if applicable) <br /> 's, El New System ( `Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> f <br /> t <br /> 3. ❑ Permit Renewal j ❑ Permit Revision [IChange of Plumber ElPermit Transfer to New List Previous Permit Number and Date Issued <br /> ! Before Expiration Owner NV <br /> W.Type of POWTS System/Component/Device: Check all that apply) <br /> X"Non-Prcssurized In-Ground ❑ Pressurized In-Ground ❑At-Grade ❑Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> L -Holding Tank a Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> a'.Dispersal/Treatment Area Information: <br /> Des r.Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> �o <br /> `SIT.Tank info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units j 4 ,- <br /> New Tanks Existing Tanks oCZ 0 <br /> Y s <br /> i Seot4o Or H . g k D 1 <br /> i Dosing Chamber [,jd D <br /> VIL 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 /> 4 WADE RUFSHOLM / /„ /_ 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX 5114,SIREN,WI 54872 <br /> VIII.County/Department Use.Only <br /> 1 Approved ' ❑ Disapproved Permit Fee Date Issue Issum Agent Signature <br /> f U Owner Given Reason for Denial $�� //Z <br /> TX.Conditions ofApproval/Reasons <br /> va sons for Disapproval �•� L�� L� IJ V <br /> haw Co�vd-v J u L I U 2024 <br /> Attach to complete pl ns for the system nd submit to the County only on paper not less than 8 1/2 x U inches n size_ <br /> Burnett County <br /> Land Services Department <br /> SBD-6398(R. i I/11) ty26 clu a * I�g%- <br />