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��pinra'1tVT\ <br /> e 1 \ Safety and Buildings Division County <br /> ;• D S r "; 1400 E Washington AveSanitary Permit Number(to be filled in by Co.) <br /> P S P.O. Box 7162 / <br /> Madison,WI 53707-7162f0� <br /> W� <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPO 383.21(2),Wis.Adt .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 /> the Department of Safety and Professional Services. Personal information you provide may be used for secondary <br /> purposes in accordance with the Priv w,s. I . 4 1 m,Slats. <br /> I. Application Information—Plea a Print 11 Information <br /> Property Owne' Name Parcel# 4 7 p a O <br /> �e S o.- 06;t l,�IO o0 <br /> Property Owner's Mai' g Addressesc INGovt. <br /> Location <br /> /r� A-/ ,(`i 7- / Govt.Lot A <br /> Ci <br /> NState Zip Code <br /> Phone Number y,, y., Section <br /> + �X 7Y�3trcle one <br /> L Type of Buil n T �N, R E ot� <br /> I <br /> yp g(check all that apply) f Lot# <br /> 1 or 2 Family Dwelling—Number of Bedrooms �C Subdivision Name <br /> ,_.., Block# <br /> ❑Public/Commercial—Describe Use / ❑City of <br /> ❑State Owned Descdbe Use CSM Number ❑Village of <br /> Town of sG0 <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑New System P-Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> I <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 /> ITV.Type of POWTS S stem/C iii o e t/ 'Llvice: Check all that al <br /> ❑Non-Pressurized In-Ground ❑Pressurized In-Ground ❑ At-Grade KMound>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(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> -3 A 1! !!k1 : 3eD I 36->a 9 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units r�. B <br /> New TanksExisting Tanks o U:NUc c <br /> Cl) y y 0. U W <br /> Septic or t'Ialdkw4amk <br /> Dosing Chamber <br /> VII.Responsibility tatement- 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.Court /De rtment Use Onl <br /> Permit Fee D Date Issued Issuing Agent Signatu <br /> Approved 11 Disapproved 7 ` p <br /> ❑Owner Given Reason for Denial $ " <br /> IX.Conditions of ApprovaVRis §¢nk'foc pigapproval <br /> D E(CEPVE <br /> Att 9omplet lens for the system and submit to the County only on paper not less than /2x incl j�pixq I �O�� <br /> �' I f4 JVIt I <br /> BURNETT COUNTY <br /> ZONING <br />