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"aia�yr County <br /> �;% \°�r� Safety and Buildings Division i,� w <br /> ,,fjti p ,j 1{ 1400 E Washington Ave Santtary PermitNumber(to be filled in by Co.) <br /> t;P $P !`) P.O. Box 7162 <br /> Madison,Wl 53707-7162 <br /> �,T�yf�JPL <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 unit (900337:1 <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 secondarypurposes in accordance with the PrivacyLaw,s. 15.04(1)(m),Stats. <br /> L A licatico Infor atioo—Please Pant All Information <br /> Property Owner's Name Parcel#/' % ry n / <br /> Property Owner's Mailing Address ` Property Location <br /> �Jpr = r/t ! Govt Lot <br /> City,State Zip Code Phone Number /,, /4, Section' t- <br /> A..._� / / circle one) <br /> T N; R <br /> / E <br /> IL Yype of Building(check all that apply) III � Lot# <br /> hor 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use ❑City of �\ <br /> ❑State Owned-Describe Use CSM Number ❑ Village of _ <br /> ❑Town of S `� <br /> III.Type of Permit: (Check only one box 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 stem/Com oneht/Device: Check all that apply) <br /> ❑Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑Mound>24 in.of suitable soil 1"'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(st) Dispersal Area Proposed(sf) System Elevation <br /> 0 r s�i —�>•� �' i 7 <br /> e —r <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units u o v <br /> New Tanks '. <br /> I'll �'� P,Sting Tanks o y `nl <br /> Septic or Belding-Tiffik /7.0 P� <br /> Dosing Chamber G <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) I PI ber's Sign 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.County/Department Use Only <br /> Approved 11 Disapproved Permit Fee O Date Issued Issuing Agen 'ignatur <br /> [IOwner Given Reason for Denial $ <br /> IX.Conditions of A�provaVReasons for,Disapproval <br /> RR ECEPVE <br /> Attach to complete plans for the system and submit to the County only on paper not less than a L2 - I i es i <br /> BURNETT COUNTY <br /> ZONING <br />