Laserfiche WebLink
County') <br /> Safety and Buildings Division /0 tl/'r�eri- <br /> - <br /> p _ 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> .\ p Madison,WI 53707-7162 11 l,'�1--25-�� <br /> State Transaction Number <br /> Sanitary Permit Application <br /> j 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(I)(m),Stats. eeEr / / <br /> I. Application Information-Please Print All Information Property Owner's Name Parcel# D 7 or. V 'J/q <br /> /Y /r.Z <br /> &W eit) GJe_ll'er 03 ooa olhipto <br /> Property Owner's Mailing Address Property Location Pc- <br /> a / 7 S D e e.c T 2 / Govt.Lot "cco( ID 3 7 3 l-1 <br /> City,State fi' "/ Zip Code Phone Number S� y, Anti 1/4, Section / 5 <br /> .SPDDAV e.r• v.r t^ .5-'Y8 01 cycle one <br /> II.Type of Building(check all that apply) Lot# T 9 N; R �� E o <br /> `7d`I or 2 Family Dwelling-Number of Bedrooms a <br /> c71Subdivision Name <br /> _� Block# <br /> ❑Public/Commercial-Describe Use ❑City of '7-- <br /> i <br /> 0 State Owned-Describe Use CSM Number ❑ Village of <br /> lki <br /> Town of R t4s k <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> i A. rrtt��rr�'' ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> � thew System ❑ Replacement System <br /> Ii <br /> II ' <br /> B. ' Permit Renewal 0 Permit Revision ❑ Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Ell <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> AA Non-Pressurized In-Ground ❑ Pressurized In-Ground 0 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 /> y�o . 7 6 93 Z.5-o 9� <br /> VI.Tank Info 1 Capacity in Total #of Manufacturer <br /> Gallons Gallons Units New Tanks Existing TanksUflu <br /> , cn ii C. p.. <br /> Septic or lialeinik /oo 0 ....-- Odd ` j-lakeze/71/-rii fog )(-- <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 /> �f <br /> ii Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 <br /> VIII.County/Department Use Only <br /> Permit Fee Date Iss ed Issuing Agent Signature <br /> I Approved ❑ Disapproved �_ <br /> Owner Given Reason for Denial $��5 5l�Z �Z5 ' � <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> 114a4 a,� se -balls E C E[I V E <br /> !Follow cx <br /> c ,w►+1 ald s--u.- C reLutlre.wm41-1-S <br /> ,Ge-r- i f.cl Irve -t Yvla.�p -b be ci�rr�d J -hD otivir,�e p rce.�S b19/I/2s MAY 0 5 2025 - <br /> Attach to c mplete plans for the system and submit to the County only paper not less than 8 1/2 x 11 c 'n size <br /> - Burnett County <br /> Land Services Department <br /> SBD-6398(R. l l/I I) _1,426 _1,, _a U 1,1130) <br />