Laserfiche WebLink
y Co.." <br /> Industry Services Division BURNETT <br /> 1400 E Washington Ave <br /> $P ! P.O. Box 7162 Sanitary Permit Number(to be filled in by Co-) <br /> Madison,W153707-7162 <br /> Sanitary Permit Application State Transaction Number <br /> In aecnrdanee with SPS 383.21(2). Wk. Adm. Code. aubmil,ra of this form tea de appropriate governmental L47686a/ <br /> unit is reel prior m obtaining a sanitary permit. Note: Application forms for sone-oaped POWTS are <br /> submitted m the Department of Safety and Professional Services. Personal information you provide may be PnsME Address h(differem Nan mailing address) <br /> used for saondury purposes in accordance with the Privacy Law,s. 15.04(p(m).Stats. <br /> 1. Application Information-Please Print All Information <br /> Pnope..y Owmara Name( Panel a m7 o06 ;�2 3 /7 i <br /> 2 f� I G ��L r -4, 03 oon o/dCD15 <br /> Property Owner Property Six ding Address PropeLocation <br /> 3B09 S/}n7 2 L-J J Govt.Lot ir.W <br /> City,Sum Zip <br /> Code Phone Number <br /> 4.1UUJb, Seven /2 <br /> T-79N". R/7 F,o&W cone) <br /> 11.Type of Building(cheek:dl that apply) Lot X <br /> F11 or 2 Famih Dwelling-Number of Bedramre 3 Subdivision Name <br /> ❑ Public/Comnnerciul-Describe Use Rivals p <br /> ❑ City of <br /> ❑ State Ownad-D,,cribe Use Elvillage of <br /> CSM banner71 <br /> 1PTownof VJ97U/e/5 <br /> IIIvgpe of Permit: (Check oohone laox on line A. Com lege line B if applicable) <br /> A. ❑ New System Replacement System ❑ To mment/Holding Tank Replacement Only ❑ Other Modification to fussing Sysent(explain) <br /> R ❑ Penni. ❑ Permit Revision ❑Change tel ❑Pennit'fransfcr to List Previous Permit Humber and Dae Issued <br /> Renewal Before Plumber p'cw Owner <br /> Expiration Iml 8�3o-i7p6 <br /> IV. Type of POWTS System/Com onent/Device: (Check all that apply) <br /> ❑ Nan-Pressurized In Graurat ❑ Pressurized In Go.,.[ ❑ A,Grade ❑ Flouted > 24 in.of l.i.ble soli 'P Afaund < 24 in.of,ui.blc soil <br /> ❑ Holden,Tank ❑Other Dispersal Compaaem(explain) ❑ Pret¢atmem Device(explain) <br /> V. DIS rsal/Trealmenl Area Information: <br /> U ign plow(gpd) Design Steil Application DiepenaI Arca Required(s0 Dispersal Area Propostd(s0 System Elevation <br /> y� Wnegpd,q/. 0 y5a ysi>- /o% S <br /> VI.Tank Into Capacity in _ <br /> Gallo s Tamlst Hof <br /> Tru.rust t-' t` — tj <br /> 2 IS <br /> NewTaNs Lsicane Tanks `v <br /> Septic or Holding Tank o7�0 00 � ✓ ❑ ❑J ❑ <br /> Dosing Chander jO — G/"7 '` ❑ ❑ ❑ ❑ <br /> Vll. Responsibilit'Statement- 1,the undersign d,awmne respnssibilit, for inundation of the PMTS shown oa the atmchcd Plano. <br /> PlumMr's Name(Prin o Pluntlwr' Sigtu t re MPIMPRS Number Business Phone Nmnher <br /> WADE RUFSHOLM (it/ 22]691 "115-349-7186 <br /> Plumhar's Address(Sued .City.Sots.Zip Code) <br /> PO BOX 514, SIREN, WI 54872 <br /> Vlll. Count'/De arlmcnt Use Dols <br /> Approved ❑ Disapproved Permit Fee Dane lgned Issuing Agent Slgnama �,�I <br /> ❑ Owrcr Given Reason for $ 7i7SOo tt GI(I I��`�n"���// I}' <br /> Dania) `ViLJ v <br /> S1 L5D 9m7�fIEJj T,e-f vr. 0 2g76&63 <br /> �� DEC - 5 20Th <br /> BURNETT COUNTY <br /> SBD-6398(R03/14) ZONING <br />