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J County <br /> Safety and Buildings Division �y�'/t1 2 <br /> J - II s 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> Madison,WI 53707-7162 Pit.1 _ 5 `/4 <br /> `Y C�(e-25--133 7/ <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 / 6 7 7 <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. (�{ I. Application Information-Please Print All Information • F70 tt)/4 +G {J^ <br /> r- <br /> Property Owner's Name Parcel# 0 7 t3 A y//6 ,JS S <br /> AAA z,m frier-AA A) /5'' Is/ o As-o00 <br /> Property Owner's Mailing Address Property Location '7 f) /D ZZ4Z7 <br /> 3)1 S�R f , 5-1- Govt.Lot <br /> City;State �,/lis Zip Code Phone Number y,, /., Section <br /> r`� <br /> cAwit OA1 5:6-00 y .� 0-7 a7$ 77�4? T y/ N; R/6 (circleon'),N <br /> °'.Type of Building(check all that apply) Lot# <br /> 16,4..cr 2 Family Dwelling-Number of Bedrooms 3 Subdivision Name <br /> Block# ..5-l`r71 A)SeAf R,llef tt;e- J 9 Ark <br /> ii ❑Public/Commercial-Describe Use 0 City of <br /> — <br /> `-- CSM Number 0 Village of <br /> ❑State Owned-Describe Use ' <br /> Kown of .5'W 1SS <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑New System Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> IL 0 Permit Renewal ElPermit Revision ❑ Change of Plumber ❑Permit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> $'Non-Pressurized In-Ground ❑Pressurized In-Ground ❑ At-Grade 0 Mound>24 in.of suitable soil 0 Mound<24 in.of suitable soil <br /> !. Holding Tank 0 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 /> 3 ov • 7 4/.27 y o W, <br /> VI.Tank Info I Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o a `? <br /> New Tanks Existing Tanks .-• o o f Y t 1 <br /> cCU in y tx: e ri. <br /> Septic or H mg Tank 8yD r <br /> Sy o� / / Sir )( <br /> Dosing Chamber 0 a <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 /e) 227691 715-349-7286 <br /> l <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 <br /> VIII.County/Department Use Only <br /> Approved ❑ Disapproved Permit Fee Date Issued Issuin ignature <br /> 54 <br /> 0 Owner Given Reason for Denial I <br /> P <br /> `fz5.� 81 a jza zs <br /> IX.Conditions of Approval/Reasons for Disapproval 1'1Z]3Itl 6-1/A5 <br /> FOl.1.ot.- •9LC Cori-.v-N 4•tt70 ST4re gE utl3E'ttge Tt5 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x t I <br /> 1 n siz <br /> BUG 0 7 2025 <br /> Burnett County <br /> SBD-6398(R. i I/I I) Land Services Department <br />