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County <br /> Safety and Buildings Division g <br /> . 1 S I i 1400 E Washington Ave Sanitary permit Number(to be filled in by Co.) <br /> Ps F.O. Box 7162 ;5797x8 <br /> Madison,WI 53707-7162 <br /> ��`Psstttriw�50P <br /> Sanitary Permit Application State TtansacuonNum/b/�* <br /> In accordanoe with SPS 38321(2),Wis.Adm.Code,submission of this forth to the appropriate governmental unit COuN I-•y /7 a de t W <br /> is required prior to obtaining a sanitary,permit Note:Application forms for stat"wned 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 Priv Law,s.15.04(1)(m),Stats. 3�©/7 „� r v/q D/}/✓� <br /> L Application Information-Please Print All Information / <br /> Property Owner's Name Parcel#0 7 03a cZ V1/6 35-5 <br /> B <br /> r^ /S� s O 300c7 <br /> Property Owner's Mailing Address / Property Location <br /> 4,Jti,7 / Govt Lot <br /> City,State Zip Code Phone Number Section 3,'S'.5-0 39 65 6 —�//y (circle one <br /> H.T e of Building(check all that apply) Lot# T_YL N, R /6 Ee or <br /> XI or 2 Family Dwelling-Number of Bedrooms 51 Subdivision Nam Q <br /> Block# �A�a15eNs cJ�'( IetJ bfrk <br /> ❑PublidCommercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> 7Town of <br /> III.Type of Permit: (Check only one boa 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 m/Com onent/Device: Check all that apply) <br /> ion-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(gpds0 Dispersal Area Required(s0 Dispersal Area Proposed(sf) System Elevation <br /> y�o , 7 G y3 G so yG <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units s, o <br /> New Tanks Existing Tanks o m <br /> a ii <br /> Septic or Holding Tank •�D 0 t <br /> Dosing Chamber e 6) OD <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 MP/1v9RS Number Business Phone Number <br /> WADE RUFSHOLM / 2A / 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 <br /> VIII.Coun /De artment Use Only <br /> Approved ❑Disapproved Permit Fee <br /> d^ O Date Issued / Issuing Agent Sign <br /> v_,, <br /> ElOwner Given Reason for Denial $�7, .D� 7�G S f C9 <br /> m coad 6nss of Approvammason,for Disapproval <br /> ECEIVE <br /> nn <br /> Attach to complete plans for the system and submit to the County only on paper not less than 512 x in JUL <br /> JUL 5 1016LU) <br /> BURNETT COUNTY <br /> ZONING <br />