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County <br /> Safety and Buildings Division t.4 /I/J e, <br /> p 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> Madison,Wl 53707-7162 <br /> C,a <br /> State Transaction Number <br /> Sanitary Permit Application <br /> 1„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. l�s 1 <br /> A piication Information-Please Print All Information Or U <br /> i Property Owner's Name Parcel# p <br /> r'o�tJ � o Do0 © od <br /> o/nte'' o ner's?,viaiiing PG Address Property Location / <br /> / 7 3� _� /�Q. /� V G� 14 Govt.Lot Ta�C 3c�39 S <br /> <, SE:ata Zip Code Phone Number 52J y4,A)a '/4, Section .3 y <br /> -�,O{•��!, L-/ 6 / 5/G ao a T (_circle one <br /> NR Eoe/-.ype of Building(check all that apply) Lot# <br /> .or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block# <br /> u Pubiic/Commercial,-Describe Use -� ❑ City of <br /> CSM Number ❑ Village of -� <br /> State Owned-Describe Use d <br /> e� Town of �/ �i7✓s "O' <br /> Cl <br /> Hai.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> ^ew System ❑ Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> D ❑Permit Renewai ❑ Permit Revision ElChange of Plumber ❑Permit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration. ! Owner <br /> 7,7.7y e 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 `�ound<24 in.of suitable soil <br /> molding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> Dispersal/Treatment Area Information: <br /> Design Flow(gpd) 1 Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> �-� yso y -a 9�,3 <br /> 7. <br /> s,n yfo Capacity in Total #of Manufacturer <br /> Gallons Gallons Units 2 <br /> New Tanks Existing Tanks o Y A <br /> U V) iy <br /> Septic or 71-14w*1­1, O D <br /> Dosing Chamber <br /> /;i.Re <br /> sporsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plum er's Signature MP/MPRS Number Business Phone Number <br /> 'NADE RUFSHOLM �/j �,� 227691 715-349-7286 <br /> i'iumber's Address(Street;City,State,Zip Code) <br /> i PO BOX 514.SIREN,W1 54872 <br /> '+ III.County/Department Use Only <br /> i Permit Fee Date Issued Issuin Agent Signature <br /> 'X' Approved i ❑ Disapproved ap <br /> ElOwner <br /> Owner Given Reason for Denial 3�7 5 — g�22 � <br /> ix.Conditions of Approvai/Reasons for Disapproval <br /> DEWE <br /> rjl(cw am cfx� Ltd S a4 mw,rvnw S AUG 2 12024 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 t/z x 11 iUch n size <br /> — Burnett County <br /> /�-{• Land Services Department <br />