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U LJ -- — I „ <br />SBD -6398 (80313) BURNETT COUNTY <br />ZONING <br />Count <br />Safety and Buildings Division <br />' . <br />1400 E Washington Ave <br />Sanitary Permi Number (to be filled in by Co.) <br />P.O. Box 7162 <br />'r <br />Madison, WI 53707-7162 <br />Sanitary Permit Application <br />State Transaction <br />AIA <br />In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental unit <br />Project Address (if different than mailing address) <br />is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are submitted to <br />the Department of Safety and Professional Services. Personal information you provide may be used for secondary <br />ourposes in accordance with the Privacy Law, s. 15.04 1 m , Stats. <br />I. Application Information - Please Print All Information <br />Property Owner's Name <br />Parcel # j 7 Od 6- a-�'�8 7-A �� l <br />A V- AlAe e <br />- 00 - <br />Property Owner's Mailing Address <br />Property Location QC <br />2 /^ <br />Govt. Lot <br />/, <br />j— � %4, Section _ <br />City, State <br />Zip Code <br />Phone Numbernl <br />O <br />/T�(circle o <br />T. N+ R �— E ,,,`�iJl <br />T(JW <br />II. Type of Building (check all that apply) <br />Lot # <br />Subdivision Name -- <br />A'1 or 2 Family Dwelling — Number of Bedrooms <br />Block # <br />❑ Public/Commercial - Describe Use <br />— <br />Cl City of <br />❑State Owned -Describe Use <br />El Village of r' <br />CSM Number <br />g Town of/¢/0/e- .S <br />III. Type of Permit: (Check only one box online A. Complete line B if applicable) <br />A. <br />❑ New System <br />AReplacement System <br />❑ Treatment/Holding Tank Replacement Only <br />Other Modification to Existing System (explain) <br />B. <br />❑ Permit Renewal <br />❑ Permit Revision <br />❑ Change of Plumber <br />❑ Permit Transfer to New <br />List Previous Permit Number and Date Issued <br />Before Expiration <br />Owner <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 />Des}t n Flow (gpd) <br />Design Soil Application Rate(gpdsf) <br />Dispersal Area Required (sf) <br />Dispersal Area Proposed (sf) <br />System 131—ation <br />60 <br />• s <br />/ o v <br />/� o v <br />x.3.0 <br />VI. Tank Info <br />Capacity in <br />Total # of Manufacturer <br />o b„ <br />Gallons <br />Gallons Units <br />New Tanks <br />Existing Tanks <br />0 o Y jj <br />'rs. <br />a U n y cn 6 P, <br />Septic or Heldin alk <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) <br />Plumber's Signature <br />MP/MPRS Number <br />Business Phone Number <br />WADE RUFSHOLM <br />227691 <br />I <br />715-349-7286 <br />Plumber's Address (Street, City, State, Zip Code) <br />PO BOX 514, SIREN, WI 54872 <br />'V.,III. Coun /De artment Use Only <br />ISE Approved <br />❑ Disapproved <br />Permit Fee <br />$ G d <br />Date Issued <br />Issuing Agent Signatur <br />❑Owner Given Reason for Denial <br />3 7S'' <br />�> <br />A9 "a 3 " �Q <br />IX. Conditions of Approval/Reasons for Disapproval <br />ECEOVE <br />Attach to complete plans for the system and submit to the County only on paper not less thanN-inchs <br />U LJ -- — I „ <br />SBD -6398 (80313) BURNETT COUNTY <br />ZONING <br />