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?1pelA0 COunty <br /> jp `� Safety and Buildings Division BURNETT <br /> 3` 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> i3t - I P.O. Box <br /> Madison,WI 53707707—7162 V � <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 <br /> unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are Project Address(if different than mailing address) <br /> submitted to the Department of Safety and Professional Services. Personal information you provide may be <br /> used for secondary 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#C� .7 CS,2 n ,,,Z C16 A -;Z C> <br /> Property Owner's Ma fling Address Property Location <br /> : -/'7 r' Govt. Lot <br /> City,State Zip Code Phone Number <br /> / 'A,, /,Section <br /> S4/ �G) <br /> f}iUF�y/' ite.l� /Jr�J U (circle one) <br /> II.Type of B ding(check all that apply) Lot# T Ili N; R�E o > <br /> 1 <br /> a Subdivision Name <br /> �[ <br /> Iq 1 or 2 Family Dwelling-Number of Bedrooms —% <br /> Block# L .5,j, <br /> ❑Public/Commercial-Describe Use / <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number Ll Village of <br /> Town of 0 A <br /> III. Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑ New System Re lacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. El Permit Renewal Ll Permit Revision 11 Change of 11 Permit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IV. Type of POWTS System/Component/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 ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V. Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units <br /> a <br /> New Tanks Existing Tanks c y <br /> " h <br /> Pv�P. U ' � rn <br /> Septic or Hokkag-Tank aC o m00 <br /> Dosing Chamber <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. T <br /> Plumber's Name(Prin t) Plumber's Signa ture MP/MPRS Number 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. CountyDepartment Use Only <br /> Approved El Disapproved Permit Fee t7 Date Issued Issuing Age i now <br /> ❑ Owner Given Reason for Denial <br /> IX. Conditions of Approval/Reasons for Disapproval <br /> �C Attach to complete plans for the system and submit to the County only on paper not less than S 12 x 11 inches in size <br /> l SBD-6398(R03/14) <br />