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,.Oheaxat �;-Te County <br /> >� Safety and Buildings Division �4/pit}e, <br /> �r'l \10, 1400 E Washington Ave Sanitary Pe it Number(to be filled in by Co.) <br /> P.O.Box 7162 <br /> V . <br /> Madison,WI 53707-7162 r <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 38321(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit <br /> is required prior to obtaining a sanitary permit. Note:Application fomes 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. Aplelication Information-Please Print All Information <br /> Property Owner's Name Parcel#© -7 p 3 cl oZ,37 /3 a j <br /> 2 r /' O S 043 O 130DO <br /> Property Owner's Mailing Address Property Location <br /> sG Govt Lot <br /> City,State Zip Code Phone Number y,, '/., Section W <br /> / • C (circle one <br /> U.Type of Building(check all that apply) <br /> Lot# T�N; R1�Eor <br /> 01 or 2 Family Dwelling-Number of Bedrooms 7 Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use ❑ City of <br /> ❑State Owned-Describe Use <br /> CSM Number ❑ Village of <br /> V y 176 0,Town of 7 X74 L AK4e <br /> III.Type of Permit: (Check only one boa on line A. Complete line B if applicable) <br /> A. %Zqew 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 onent/Device: Check all that apply) <br /> ❑l Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑Mound?24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> 129 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 /> w <br /> Gallons Gallons Units <br /> New Tanks Existing Tanks o & A ea <br /> ri U �, rn w C7 P. <br /> $opse or Holding TalcJr-D <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 /_; 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 /> Approved ❑Disapproved Permit Fee Date Issued Issuing Agen Sign re <br /> $ Q <br /> ❑ Owner Given Reason for Denial 7-do ` 1-1 <br /> LY.Conditions of Approva�URessons for Disapproval/ sCl�f�t!� ��� ,/ ROOM V <br /> XA N �{tl /c, �.v!✓�a t 7 rr�vi(�Gf iic+9 Y nn <br /> w-'CL �e l/,v,l r Q�%rc wa� • JUL 20 <br /> 2017 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 t6 x 1 mch n size <br /> BURNETT COUNTY <br /> --- ---- --- -- ZONING <br />