Laserfiche WebLink
County <br /> Safety and Buildings Division ,LS <br /> p = 201 W.Washington Ave., P.O.BOX 7162 Sanitary Permit Number(to be filled in by Co.) <br /> SP S Madison,WI 53707-7162 4N -.2y_o�33 <br /> i Sanitary Permit Application State Transaction Number <br /> p 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. 02gn <br /> I. Application Information-Please Print All Information /pG <br /> ' Property Owner's Name Parcel# p 7 a,9 D yD m <br /> �e1e. r .s 6 0 0 0 <br /> ! Property Owner's Mail in�Address f Property Location — <br /> b /sGo� .c ve Govt.Lot ' <br /> City,State Zip CodePhone Number <br /> /<, �/4, Section y <br /> �•� Sknt r S7/8'Yb �J _O b l�� y� (circle one <br /> II.Type of Build (check all that apply) Lot# T�Q_N; R�_E or� <br /> l 1 or 2 Family Dwelling-Number of Bedrooms ` b Subdivision Name <br /> �l�`� 'Block# o`r b oersid e »7e5 <br /> + ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use <br /> CSM Number ❑ Village of <br /> own of <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. INew System ❑ Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> i <br /> ' B. ' ❑ 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 /> 7,�Jon-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) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> - 7 y 6sa <br /> VI.Tank Info I Capacity in Total #of Manufacturer <br /> Gallons Gallons Units c <br /> c0 U U U H <br /> New Tanks Existing Tanks <br /> cC U v1 U. CU 0» <br /> Septic or HGldiug XFenk <br /> �av p0 �tJerw�s <br /> Dosing Chamber <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 /> i <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 <br /> V11I.Coun /De artment Use Only <br /> ( ,Approved ❑ Disapproved Permit Feed Dat Issu d Issuing Agent Signature <br /> ❑Owner Given Reason for Denial <br /> $�l25 1113�Z670 <br /> IX.Conditions of Approval/Reasons for Disapproval [E ^E <br /> ME <br /> ► ku+ oij se,-l-loac�s D <br /> rv14,-3 W ccun+E tatd �-I-�,-� re���ve rne,ri►-�S SEP 12 2024 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 Nchi n size <br /> Burnett County <br /> Land Services Department <br /> SBD-6398(R. 11/]1) yZ5 cKitij-4+103-3 <br />