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- Safety and Buildings Division cou r t)e-7 <br /> ,- • n = 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> p S Madison,WI 53707-7162 31W-25_ /21-7 <br /> - tan ( 67/93 <br /> State Transaction Number <br /> Sanitary Permit Application <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 A i ess(i'different than mailing address) <br /> the Department of Safety and Professional Servies. Personal information you provide may be used for secondary 27 * <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. J <br /> I. Application Information-Please Print All Information L.0/0 e•—• R fie- d► <br /> Property Owner's Name Parcel# 0 -7 O a b v1 yes /L o79 <br /> C4 f4r1e-s Ae f9 / os/ aoa m/aooa 4 /383O <br /> Property Owner's Mailing Address Property Location PG/ <br /> a/6_.5.- 15 y 6 e.ls /(Q' Govt.Lot _ <br /> Ciotti..State Zip Code ,ode Phone Number ,/// SE /,/E- 'A, Section 2 7 <br /> W e lotiliti <br /> 51 er A-) ' 1. / 7.3 7/J 79� 85 6 4 T 4/P N; R a (circle <br /> I.Type of Building(check all that apply) Lot# <br /> or 2 Family Dwelling-Number of Bedrooms ....3 / Subdivision Name <br /> _e Block# --- <br /> 0 Public/Commercial-Describe Use <br /> ❑ City of <br /> CSM Number ❑ Village of '---- <br /> ❑State Owned-Describe Use '/ <br /> /'77 Town of 04 k /,9-,'d <br /> in.Type of Permit: (Check only one box on line A. Complete line B if applicable)) <br /> A. <br /> New System gReplacement System 0 Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑ List Previous Permit Number and Date Issued <br /> 0 Permit Revision Change of Plumber ❑Permit Transfer to New <br /> i Before Expiration { Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> d57.4lon-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil 0 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) I Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 4f5-o ! , 7 4V 3 16-73 1?s- <br /> VI.Tank Info Capacity in Total #of Manufacturer y <br /> Gallons Gallons Units -o B U 2 <br /> New Tanks I Existing Tanks � o i p 2 i2 � <br /> ct U in cn w C7 0.. <br /> Septic or .36e, 7.5-0 <br /> /b56 p'j /jl tfre..)G,SG a^r"'W 1-- <br /> Dos ng Chamber <br /> VU.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 L� 227691 715-349-7286 <br /> I <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 <br /> VIM County/Department Use Only <br /> Permit Fee Date Issued Issuing A ignature <br /> g Approved E ❑ Disapproved ,�11 % <br /> ❑Owner Given Reason for Denial $ f2✓ 8 f(pl Z025 t ' l' <br /> IX.Conditions of Approval/Reasons for Disapproval C 172,30 �C 4ZS- <br /> ftfEEr ACC scrBAUJ-S IIECIEOVE -r <br /> Au.t.w 41-C Caa vr/ 4v0 fr9Tc--- 3EQurizesw4/73" <br /> AII( 0 4 2025 U/ <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 t/:E 11 :hes in size <br /> Burnett County <br /> SBD-6398(R. i 1/1 I 1 Land Services Department <br />