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};raw:ttr County <br /> Safety and Buildings Division <br /> 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> S P 5 Madison,WI 53707-7162 <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 /> purposes in accordance with the Privacy Law,s. 15.04 1 m Stats. ��I I. A O Application Information—Please Print All Information /h A- <br /> ! Property Owner's Name Parcel#6 7 /8 a2 3 9 3 3 <br /> a o r'r► e. o J-5 Z- S /S 6 S d; o ao <br /> Property Owner's Mailing Address Property Location RC-/TU Y <br /> 3 �5, s 70 <br /> Govt.Lot <br /> City,State Zip Code Phone Number I) , �_, -33 <br /> / leJ /<, � /<, Section <br /> /3 6 y� ©yS/ (circle one <br /> T 3f N; R E <br /> II.Type of Building(check all that apply) Lot# _ 1(� <br /> V. or 2 Family Dwelling-Number of Bedrooms / Subdivision Name <br /> Block# �� /e -f e r l`A t_ <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> J State Owned-Describe Use CSM Number ❑ Village of <br /> { Town of <br /> Ili.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A* X%New System ❑ Replacement 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 /> Before Expiration Owner <br /> IV.Type of POWTS S stem/Con onent/Device: Check all that a 1 <br /> 0 Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> I ❑ 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 Elevati-onn, <br /> 6 t> 9'ov 9ov yG,.� <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o fl <br /> c�C U U <br /> New Tanks Existing Tanks o aj <br /> ��^^�� cCU Cony ~n LC7 a <br /> Septic or i �aak o r e 5 L C3 <br /> ` Dosing Chamber <br /> j 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 /> Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX 5I4,SIREN,WI 54872 <br /> VIII.County/De artment Use Only <br /> Approved ❑ Disapproved Permit Fee Date Issued Issuing Agent Signature <br /> ❑Owner Given Reason for Denial $195� 3'�9�ZF)25 <br /> IX.Conditions of Approval/Reasons for Disapproval -- -- - <br /> Vv IE <br /> hlD W CtV 60UA-A� aid S4 ✓jc '/T47 ,-r-�l In <br /> MAR 18 2GL5 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 c in size <br /> Burnett County <br /> Land Services Department <br /> SBD-6398(R. I I/I I) $qll� (NAk1OL1707-5 <br />