Laserfiche WebLink
� r ay� Comity 2 <br /> Safety and Buildings Division U ti / N C <br /> -( 0 K' 1400 E Washington Ave Sanitary Permit N (to be fdled in by Co.) <br /> �g P S ' P.O. Box 7162 <br /> Madison,WI 53707-7162 <br /> J7a <br /> Sanitary Permit Application State TraosactionNumber <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 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 p <br /> purposes in accordance with the Privacy Law,s.15.04 1 (m),Stats. o j '7 <br /> I. Application Information-Please Print All Information <br /> Prope Owner's NameParcel# 67 D 0 ax O <br /> A0 -Q_ A A) j-c_/'SO/L) 05 oD I 6 OBc) <br /> Property Owner's Mailing Address / Property Location In- <br /> a s rti '7- Govt Lot <br /> City, tate Zip Code Phone Number E ,�� 1114, section,�C <br /> re-Ole-or i C J- �.7_7 <br /> (circle one <br /> II.Type of Building(check all that apply) Lot# T '/0 _N; R =E <br /> X1 or 2 Family Dwelling-Number of Bedrooms 3 Subdivision Name <br /> _ Block# <br /> ❑Public/Commercial-Describe Use <br /> r' 11 City of � <br /> ❑State Owned-Describe Use CSM Number 11 Village of <br /> Va&7 KTown of 17A <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A- ❑New System ❑Replacement Sy <br /> stem A 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 Owaer <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(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sl) Syste=Elevation <br /> O C) I t•-- <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units w o d o <br /> New Tanks Existing Tanks w m <br /> a U rn y in i7.3 GL <br /> �apg'eor Holding Tank o7Onr� <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) Plumber's Signature MP/MPRS Number Business Phone Number <br /> WADE RUFSHOLM 1227691 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 Date Issued Issuing Agent Sign <br /> ❑Owner Given Reason for Denial 00 <br /> 376 0O 7-,?o -16 <br /> UL Conditions of Approval/Reasons for Disapproval <br /> e a� RFd"of9,3.3 00 oiv ,B'y y�CCnu. LK. <br /> /p rets /half Le 474 or' 46oat 93S,00 y,ttiv�t•f D ���0 v <br /> 1/r•Yfs JUL 2 0 2016 <br /> Attach to complete plans for the system and submit to the County only on paper not less than a I 1 a in size <br /> _ BURNETT COUNTY <br /> ZONING <br />