Laserfiche WebLink
County <br /> -" Safety and Buildings Division ,B ew n1 a. <br /> 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> S P Ri P.O. Box 7162 <br /> -;\ S/ Madison,WI 53707-7162 <br /> Tra <br /> Sanitary Permit Application State nsaction Number <br /> 27�son3 <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 /> Bthe Department of Safety and Professional Services. Personal information you provide may be used for secondary ��/ <br /> purposes in accordance with the PrivacyLaw,s.15.04(1)(m),Stats. <br /> I. Application Information—Please Print All Information <br /> Property Owne' Name Parcel# p 7 O o2 3 c' <br /> ( W 0 / 000 m/moo D <br /> Property Owner's Mailing Address Property Location PC/ <br /> Govt.Lot <br /> City,State Zip Code Phone Number �19 1/4, ^1E %4, Section <br /> 1^ I t /`� 6 �_ ((oirole ones <br /> �" E�-OfI fes' T .� N; R�E or@L.) <br /> II.Type of Building(check all that apply) Lot# <br /> - � Subdivision Name <br /> ❑1 or 2 Family Dwelling—Number of Bedrooms <br /> Block# <br /> Public/Commercial—Describe Use L _ �/y1 'lOc <br /> ❑ City of <br /> CSM Number ❑ Village of <br /> ❑State Owned—Describe Use <br /> V y�2 Keown of /n <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑New System eplacement System ❑ Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> ❑Permit Transfer to New List Previous Permit Number an/yDa <br /> d Date Issued <br /> go <br /> ElB. Permit Renewal ❑ Permit Revision 11 Change of Plumber Asa I /V. <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: Check all that a I a <br /> ❑Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑Mound>24 in,of suitable soil ound<24 in.of suitable s <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(st) Dispersal Area Proposed(st) System Elevation <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units 1' <br /> o d = <br /> cd v U Fi `v y v <br /> New Tanks Existing Tanks <br /> septic or Holding-Tank <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) Plums 5 M7/691 Ntunber Business Phone Number <br /> WADE RUFSHOLM /! 227691 715-349-7286 <br /> 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 Issued Issuing Agent S' aiu <br /> Approvcd ❑ Disapproved 0 <br /> ❑ Owner Given Reason for Denial $ �� 0� <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> RR ECCEIVE <br /> EP_��n <br /> Attach to complete plans for the system and submit to the County only on paper not lets than 8 In 1 in in <br /> BURNETT COUNTY <br /> ZONING <br />