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- I S -iv <br />�f -aunty <br />Safety and Buildings Division <br />ff <br />1400 E Washington Ave <br />Sanitary Permit Number (to be filled in by Co.) <br />== S P.O. Box 7162 <br />5A VV - 18 - a 5 <br />���� Madison, WI 53707-7162 <br />csT lg��`l <br />(Q6Q�a(0 <br />�� <br />Sanitary permit ApplicationState%TransadionNumber <br />1n accordance with SPS 38321(2), Wis, Adm. Code, submission of this form to the appropriate governmental unit <br />Note: Application forms for state-owned POWTS are submitted to <br />/'' �� <br />Project Address (if different than mailing address) <br />is required prior to obtaining a sanitary permit <br />the Department of Safety and Professional Services- Personal information you provide may be used for secondary <br />purposes in accordance with the Privacy Law, s. 15.04(1)(m), Stats_ <br />L Application Information — Please Print All Information <br />Property Owner's Name <br /># 0 •7 0 -3� � '/0/ � /` 7 <br />%Parcel <br />4 %6 <br />r ->y O cel) O/,?enn 0 <br />Property Owner's Mailing Address p <br />-7 <br />-7 g <br />Property Location p c- <br />Govt Lot <br />L y, �'/y Section <br />City, State <br />Zip Code <br />Phone Number <br />f <br />c/r^ Gx%%� <br />a �%�'© <br />_� J3% <br />^y_� <br />T O N; R1IEon(�".-� <br />II. Type of Building (check all that apply) <br />Lot # <br />Subdivision Name <br />0 or 2 Family Dwelling —Number of Bedrooms <br />Block # <br />City of <br />❑ Public/Commercial — Describe Use <br />f <br />❑ village of <br />CSMNumber <br />❑State Owned — Describe Use <br />�-` <br />`Town Of(d/U% O/, <br />1H. Type of )Permit: (Check only one box on line A- Complete line B if applicable) <br />A" <br />❑ New System <br />Replacement System <br />❑ Treatment/Holding Tank Replacement Only <br />❑ Other Modification to Existing System (explain) <br />R- <br />❑ Permit Renewal <br />El Revision <br />Change of Plumber <br />❑ Chan <br />❑ Permit Transfer to New <br />List Previous Permit Number and Date Issued <br />Before Expiration <br />Owner <br />IV. T e of )?OWTS S m/Com onent/Device: Check all that apply) <br />Non -Pressurized In -Ground ❑ Pressurized ln-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) <br />Design Soil Application Rate(gpdsf) <br />Dispersal Area Required (st) <br />C> <br />Dispersal Area Proposed (sf) <br />System Elevation <br />?� <br />3 (7, 0 <br />y� <br />y }I <br />,a <br />VR. Tank Info <br />Capacity in <br />Total # of Manufacturer <br />Gallons <br />Gallons Units r, i t jRT5, <br />New Tanks Existing Tanks <br />do :g 2 y an Z M <br />Septic or Haldiug.Tank <br />41 / <br />� 1 <br />Dosing Chamber <br />Q�d <br />CJ <br />VRI. Responsibility Statement- 1, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans <br />Plumber's Name (Print) <br />Plumber's Signature 01 <br />MP/MPRS Number <br />Business Phone Number <br />WADE RUFSHOLM <br />1227691 <br />715-349-7286 <br />Plumber's Address (Street, City, State, Zip Code) <br />PO BOX 514, SIREN, WI 54872 <br />Coun /De artment Use Only <br />Approved <br />❑Disapproved <br />Permit Fee D <br />$ D <br />?7 <br />Date Issued <br />Issuing Agent Signature <br />c� / 6 <br />5-- 7 <br />❑ Owner Given Reason for Denial <br />IX. Conditions of Approval/Reasons for Disapproval D�ECE#Vrrft <br />MAY 0 <br />Attach to complete plans xor the system aua suo WXJ to me wuuq ouq vu PaNca u.. — �....... ,......- ...-�--. --- --- <br />BURNETT COUNTY <br />-- ---- ----- ZONING <br />