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0 1V\N_;.1f�. . County <br /> Safety and Buildings Division y rld e,74— <br /> D 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> P S Madison,WI 53707-7162 P �� /,r1�3 <br /> 1 State Transaction Number <br /> Sanitary Permit Application <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 /> 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. <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel#p `7 D O 2 3 9 <br /> L Rrr S Nine s' oG- od © 3.7coLl <br /> Property Owne s Mailing Address n Property Location 1-(AY- L1,� ZZ S <br /> PC-, <br /> Go Lot <br /> City,State C Zip Code / Phone Number y4, %4, Section_� <br /> i Aes � �o3i f circle one <br /> II.Type of Building(check all that apply) Lot# T�N; R � E o <br /> Ter 2 Family Dwelling-Number of Bedrooms �— Subdivision Name <br /> Block# <br /> { ❑Public/Commercial-Describe Use �® ❑ City of <br /> i <br /> f ❑State Owned-Describe Use �— CSM Number ❑Village of /�/ C <br /> jY-Town of c0 4IV/ P. .S <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> i A. ❑New System �Re lacement System Treatment/Holding Tank Replacement Only Other Modification to Existing System(explain) <br /> ) <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> I Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: Check all that a I <br /> i ❑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 /> 3a � <br /> VI.Tank Info I Capacity in Total #of Manufacturer <br /> Gallons Gallons Units 1, o <br /> New Tanks Existing Tanks y o <br /> v) <br /> vwptiaor Holding Tank ov O� 3 A)/esP_1-,� /y�L <br /> i 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 Num7715-349-7286 <br /> usiness Phone Number <br /> i WADE RUFSHOLM / 227691 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 <br /> VIII. ounty/De artment Use Only <br /> Approved ❑ Disapproved Permit Fee Date Issued Issuing Agent Signature <br /> ❑ olD <br /> Owner Given Reason for Denial $ /�/ <br /> IX.Conditions of Approval/Reasons for Disapproval _ <br /> fot(ow a coin+Y aticf S <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2�411 ipches in`size <br /> Burnett County <br /> Land Services Department <br /> SBD-6398(R. I I/I I) <br />