Laserfiche WebLink
County <br /> Safety and Buildings Division 44/—A) <br /> f _ 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> P Madison,Wl 53707-7162 `�AN ✓°��'—.Z� <br /> a <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 Slats. r <br /> I. Application Information—Please Print All Information /<� /45 5 <br /> Property Owner's Name Parcel# O 7 01A -2 yv 4 j O <br /> Property Owner's Mailing Address p Property Location-ra `D <br /> r�33- &e r;�1 In e44 >� Govt.Lot <br /> City,State Zip Code Phone Number y4 /4, Section <br /> j �503 219 �� �� kcircle one <br /> II.Type of Build ng(check all that apply) Lot# T N; Rom_E ot� <br /> y Subdivision Name <br /> or 2 Family Dwelling—Number of Bedrooms / <br /> _ Block# fa <br /> ❑Public/Commercial—Describe Use ❑City of _ <br /> i <br /> ❑State Owned—Describe Use ! CSM Number ❑ Village of —}— <br /> Town of y l7c— s <br /> j III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ew System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> Y P Y g P Y g Y ( P ) <br /> B• f' ❑ 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 apply) <br /> A.Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑At-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> i <br /> 1 ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dis ersai/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units a c <br /> U L y <br /> i New Tanks Existing Tanks 0 3 Y jj <br /> U ti wC7 A. <br /> ; <br /> septic orH4dw&Z-k <br /> Dosing Chamber <br /> VII.Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Numbe7715-349-7286 <br /> usiness Phone Number <br /> WADE RUFSHOLM 1 227691 <br /> i <br /> Plumber's Address(Street,City,State,Zip Code) <br /> f PO BOX 514,SIREN,WI 54872 <br /> i <br /> VIII.Coun /De artment Use Only <br /> Permit Fee Date Issued Issuing Agent Signature <br /> ! Approved ❑ Disapproved _ <br /> S ❑ Owner Given Reason for Denial <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> E��MYE <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 in x 11 inche3 m s <br /> s <br /> t Li �_»ems <br /> Burnett County <br /> SBD-6398(R. I I/11) Land Services Department <br /> 110�7 -9 147- <br />