Laserfiche WebLink
,��YaRTbl6:yr �— <br />Safety and Buildings Division <br />CO <br />BURNETT <br />Sanitary Permit Number (to be filled in by Co.) <br />1400 E Washington Ave <br />i? p P.O. Box 7162 <br />y Madison, —7162 <br />MdiW 153707 <br />r/ <br />/ 7 g <br />/�y1 <br />� <br />Sanitary Permit Application <br />State Transaction Number <br />In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental <br />Project Address (if different than mailing address) <br />unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are <br />submitted to the Department of Safety and Professional Services. Personal information you provide may be <br />used for secondary purposes in accordance with the Privacy Law, s. 15.04(1)(m), Stats. <br />T ��'rr�a <br />U l RXG DOTQ2y <br />I. Application Information - Please Print All Information <br />Property Owner's Name R940A *AOdt: 812RY 61565 <br />REl�N J.M.1` <br />ka /d <br />Parcel ;Y <br />l AQ ��WI 5 701 <br />_ , -z. <br />Property Owner's Ma fling Address <br />r' <br />Property Location <br />019 �/ e, �, ,1 job' ri` <br />Govt. Lot rJ <br />#W_ ��) 'A,Section r7r <br />City, State <br />Zip <br />Phone Number <br />�l ✓� E /1 �" <br />cCode <br />c7 <br />! 9/.3 <br />�i t� <br />J / l - U !�� <br />� C, �W// (circle one) <br />T N; R E or <br />II. Type of Building (check all that apply) <br />Lot # <br />Subdivision Name <br />X1 or 2 Family Dwelling - Number of Bedrooms 6�?, <br />IS3L_ <br />Block # <br />❑ Public/Commercial - Describe Use <br />❑ City of —' <br />-- <br />El State Owned -Describe Use <br />El village of <br />V, Town of /%� �- e. /'tiC3 <br />CSM Number <br />V j � <br />5 P3� <br />III. <br />Type of Permit: (Check only one box on line A. Complete line <br />B if applicable) <br />New System <br />❑ Replacement System <br />fl Treatment/ Tank Replacement Only <br />❑ Other Modification to Existing System (explain) <br />B. <br />❑ Permit Renewal <br />❑ Permit Revision <br />❑ Change of <br />❑ Permit Transfer to New <br />List Previous Permit Number and Date Issued <br />Before Expiration <br />Plumber <br />Owner` <br />__8 9 89 <br />I 1- I <br />j 'J 1/0- 1 S <br />IV. <br />Type of PO TS System/Component/Device: (Check all that apply) cc- <br />❑ Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound > 24 in., 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) <br />Design Soil Application Rate(gpdsf) <br />Dispersal Area Required (sf) <br />Dispersal Area Proposed (sf) <br />System Elevation <br />VI. Tank Info <br />Capacity in <br />Total i/ of <br />Manufacturer <br />Gallons <br />Gallons Units <br />a <br />o $ <br />New Tanks <br />Existing Tanks <br />a <br />d <br />Un <br />Septic or Holding Tank <br /><� <br />Dosing Chamber <br />7 J o <br />7:5 O <br />e"a C- <br />VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. <br />Plumber's Name (Priv t) <br />WADE RUFSHOLM <br />Plumber's Signa tureMP/MPRS <br />/ % / <br />Number <br />227691 <br />Business Phone Number <br />715-349-7286 <br />, <br />Plumber's Address (Street , City, State, Zip Code) <br />PO BOX 514, SIREN, WI 54872 <br />VIII oust Department Use Only <br />Approved <br />El Disapproved <br />Permit Fee <br />Date Issued <br />Issuing t Signature <br />❑ Owner Given Reason for Denial <br />$ <br />z�f �b 201 <br />IX. Conditions of Approval/Reasons for Disapproval t <br />k' <br />Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 inch I IRNIETT COUNTY <br />�V, I��I <br />SBD -6398 (R03/14) ZONING <br />