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,�arsig�\ County Q <br /> /( `"I °;' Safety and Buildings Division <br /> !- �"; 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> a W IP M' P.O. Box 7162 <br /> S /W Madison,WI 53707-7162 <br /> 1 ✓W <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 Services. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s.15.04(1 m,Stats. <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# p p c <br /> ®!!� o Id �7 08-o?- 1�5- 03 <br /> Property O er's Mailing Address o Property Location <br /> s-`7/S3 ��nJo1 /7 (� 'f Govt.Lot <br /> City,state Zip Code Phone Number /4, /4, Section <br /> /y� , /{� j� e 9p (circle on <br /> VP/5 /iv�J a J 5 7 / / / /� J'Clc/D T e N. R E o� <br /> II.Type of Building(check all that apply) �7 Lot# �- <br /> or 2 Family Dwelling-Number of Bedrooms "� O Subdivision Name <br /> //// �r Block G 4//✓� TS/� Te 5'16 ds <br /> ❑Public/Commercial-Describe Use 12 ❑City of <br /> CSM Number 11 Village of <br /> ElState Owned-Describe Use <br /> Pr-Town of ctJ e `l/ <br /> Ir <br /> III.Type of Permit: (Check only one b x on line A. Complete line B if applicable) <br /> A. 1KN System ❑ReplacementSystem ElTreatment/Holding Tank Replacement Only 11 Other Modification to Existing System(explain) <br /> ❑ Chan List Previous Permit Number and Date Issued <br /> B. ❑ Permit Renewal El Permit Revision Change of Plumber ❑Permit Transfer to New t�QQ/' R <br /> Before Expiration Owner I v�0 �I- <br /> IV.T e of POWTS S stem/Com onent(Device: Check all that i 1 C <br /> n-Pressurized In-Ground ❑Pressurized In-Ground ❑ 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.Dis ersai/Treatment Area In r atmrl <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) 5Displ Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> Seo , `7 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units a b <br /> C5 <br /> New Tanks Existing Tanks 2 o +°'• ,��. `� <br /> Septic or Nold+nl <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 Number Business Phone Number <br /> WADE RUFSHOLM G �'� � 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 <br /> VIII.Court /De artment Use Only eS <br /> Permit Fee Date Issued Issuing Agent Sign <br /> l� Approved ❑ Disapproved <br /> h ❑Owner Given Reason for Denial <br /> IX-Conditions of Approval/Reasons for Disapproval <br /> ReEOEthEAttach to complete plans for the system and submit to the County oniy on paper not less an 81/ts it 1 9 2016 <br /> .__---- <br /> BURNETT COUNTY <br /> ZONING <br />