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SBD -6398 (80313) <br />L. P.c.c pl.... .or inc sysicm and sworn to me "unry omy on paper not Jeshan T x V rgcpes In Sze L V w <br />BURNETT COUNTY <br />ZONING <br />LIMA <br />County <br />Safety and Buildings Division <br />© S IK <br />1400 E Washington Ave <br />P.O. Box 7162 <br />Sanitary Permit Number (to be filled in by Co.) <br />�o���' <br />Madison, WI 53707-7162 <br />nn <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 unit <br />is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are submitted to <br />Project Address (if different than mailing address) <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 />a <br />1/ / <br />I. Application Information Please <br />— Print All Information <br />Property Owner's Name <br />ei�h �y��e• e <br />Parcel # t) '7 O O oZ 35? 10 W <br />o a o0 0 0/ oad <br />Property Owner's Mail ing Address <br />Property Location <br />✓ <br />Govt. Lot <br />A&)/.,�� /., Section <br />City, State <br />Zip Code <br />Phone Number <br />5 / 9,F 7 <br />(circle one <br />Tc3,9 N; R— 16_EaO <br />II. Type of Building (check all that apply) <br />Lot # <br />�1 or 2 Family Dwelling — Number of Bedrooms <br />/ <br />r' <br />Su <br />Subdivision bdivson Name <br />N <br />Block # <br />`— <br />❑ Public/Commercial — Describe Use <br />❑ City of <br />❑ State Owned — Describe Use <br />❑ Village of �— <br />CSM Number <br />Town of !0 ie <br />III. Type of Permit: (Check only one box on line A. Complete line B if applicable) <br />A. <br />1''L New System y <br />❑Replacement 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 <br />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 />AHolding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain) <br />V. Dis ersal/rreatment Area Information: <br />Design Flow (gpd) <br />Design Soil Application Rate(gpdsf) <br />Dispersal Area Required (so <br />Dispersal Area Proposed (sf) <br />System Elevation <br />VI. Tank Info <br />Capacity in Total # of <br />Manufacturer <br />Gallons Gallons Units <br />L c b <br />New Tanks Existing Tanks <br />0 y <br />y <br />a U in <br />Selpftbr Holding Tank <br />r7 o O Q <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 />/ J� <br />227691 <br />715-349-7286 <br />Plumber's Address (Street, City, State, Zip Code) <br />PO BOX 514, SIREN, WI 54872 <br />II. Count /De artment Use Only <br />Approved <br />El Disapproved <br />Permit Fee <br />Date Issued <br />Issui Agent Signature <br />El Owner <br />Owner Given Reason for Denial <br />� �� <br />I l J <br />71 / <br />IX. Conditions of ApprovalfReasons for Disapproval <br />VE <br />0%15= i !30j2 nn <br />SBD -6398 (80313) <br />L. P.c.c pl.... .or inc sysicm and sworn to me "unry omy on paper not Jeshan T x V rgcpes In Sze L V w <br />BURNETT COUNTY <br />ZONING <br />LIMA <br />