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COU[1t}' <br /> I Safety and Buildings Division y/yt)e <br /> � D 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> S <br /> PBox st LM <br /> S <br /> Madison, <br /> WI 537707-7162 <br /> . <br /> <A�,I, <br /> Sanitary Permit Application State <br /> Transaction Number <br /> In accordance with SPS 38321(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit Gam^'�r /1 ed{r w <br /> is required prior to obtaining a sanitary permit. Note:Application forms for state-owned POWTS are submitted to Project Address(if different than mmlin address) <br /> the Department of Safety and Professional Services. Personal information you provide may be used for secondary C/q rsO/J �� <br /> purposes in accordance with the Privacy Law,s. 15.04(I)m,Stats. <br /> I. A licationInfor ation-Please Pr'nt All Information <br /> Property Owner's Name Parcel# <br /> C, � S O S 00 O/6©d0 <br /> Property Owner's Mailing Address Property Location P� <br /> 3 g-DGovt.Lot_ <br /> City,State Zip Code Phone Number y, /., Section / > <br /> I/7� 15�5-1,2 6 (circle one <br /> H.Type of Building(check all 141 aFply) Lot# T�si N; R _E o W <br /> yor 2 Family Dwelling-Number of edrooms'll Subdivision Name <br /> 54 <br /> _ Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use <br /> r <br /> SM Number ❑ Village of <br /> VY 101,5-1-7 Ei�l1 own of S�o <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 /> B. ❑Permit Renewal ❑Permit Revision ❑ Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS S stem/Com one t/Device: Check all that apply) <br /> ❑Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> Holding Tank ElOther Dispersal Component(explain) ElPretreatment 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 /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units U10 <br /> New Tanks N Existing Tanks <br /> II U <br /> Boor Holding Tank ae> �O r eIG/49—!j G p <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 �T MP/MPRS Number Business Phone Number <br /> WADE RUFSHOLM /.J 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 <br /> VIII.Coon /De artment Use Only <br /> Permit Fee Date Issued Issuing Agent Signature <br /> Approved 11 Disapproved ? _ ,p41 J<Jlj�� <br /> ❑Owner Given Reason for Denial $ 3 7s ' 0' S /6 <br /> 1X.Conditions of Aproval/Reasons for Disapproval EC E nn N� <br /> p tyu� <br /> Nd�GfiN9 [An111s Hit• O`UY moi' r/ . ' <br /> MAY 16 2016 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 5 1/2 11 nc in size <br /> BURNETT COUNTY <br /> ZONING <br />