Laserfiche WebLink
iNrs� <br />Safety and Buildings Division <br />County/� <br />Sanitary Permit Number (to be filled in by Co.) <br />.+. <br />1400 E Washington Ave <br />S <br />S <br />P.O. Box 7162 <br />Madison, WI 53707-7162 <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 unit <br />is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are submitted to <br />11114- <br />Project Address (if djfferent 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 />Or/ <br />L6e- SN <br />All Information <br />I. Application Information- Please Print <br />Name <br />Parcel # 0 7_ d / C,- ;2 3 $- /.5' OS- <br />Property Owner's <br />r4 � i9-�^o z <br />/��41,2 7- Cy 13 049 a <br />Prope Owner's Mailing Address <br />1 <br />Property Location <br />369 L A k--e-v, ecJ 0T <br />Govt. Lot <br />1/,, %., Section <br />City, State <br />Zip Code Phone <br />Number <br />C Y S �/ l � / ✓ • <br />S�o <br />circle one <br />T � N, R E oN <br />11. Type of Building (check all that apply) Lot <br />Number Bedrooms <br /># <br />"q, ` <br />SubdivisionName <br />td tlor 2 Family Dwelling- of <br />L <br />Block# <br />,,+rt'n. -5tAd, <br />❑ City of <br />❑ Public/Commercial - Describe Use ^_ <br />— CSM <br />❑Village of <br />Number <br />C1State Owned - Describe Use <br />�^Town <br />of L. ,67e L/ e l�'� <br />III. Type of Permit: (Check only one box on line A. Complete line B if applicable) <br />`4• <br />❑ New System <br />� Replacement System <br />❑ Treatment/Holding Tank Replacement Only <br />❑ Other Modification to Existing System (explain) <br />B. <br />❑ Permit Renewal <br />ElPermit Revision <br />11Change of Plumber <br />❑ Permit Transfer to New <br />List Previous Permit Number and Date Issued <br />Before Expiration <br />Owner <br />IV. Type of POWTS System/Component/Device: Check all that apply) <br />❑ Non -Pressurized In -Ground ❑ Pressurized In -Ground ❑ At -Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil <br />KHolding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain) <br />V. Dis ersaUTreatment Area Information: <br />Design Flow (gpd) <br />Design Soil Application Rate(gpdsf) <br />Dispersal Area Required (so <br />Dispersal Area Proposed (so <br />System Elevation <br />VI. Tank Info <br />Capacity in <br />Total <br /># of Manufacturer <br />[ <br />Gallons <br />Gallons <br />Units <br />a <br />d U <br />j u <br />y <br />n <br />New Tanks Existing Tanks <br />o <br />a U <br />� H <br />y <br />yr ii C7 a. <br />,$y or Holding Tank <br />©O �— <br />QD <br />/0 O <br />Dosing Chamber <br />VII. Responsibility Statement- 1, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. <br />Plumber's Name (Print) Plumber's Signature MP/MPRS Number Business Phone Number <br />227691 715-349-7286 <br />WADE RUFSHOLM <br />Plumber's Address (Street, City, State, Zip Code) <br />PO BOX 514, SIREN, WI 54872 <br />VIII. Coun /De artment Use Only <br />Approved <br />Disapproved <br />Permit Fee <br />$ <br />Date Issued <br />Issuing Agent Si atw <br />❑ Owner Given Reason for Denial <br />375-D0 19 <br />-17 - <br />IX. Conditions of ApprovaMeasons for Disapproval <br />fin <br />a. <br />rMPROVED <br />Mm E C`�F. VE <br />Attach to complete pians mr the system -nu suu— t- .- <,--.•.r .••j, ...• r -r . ••�. • FW <br />SBD -6398 (80313) SEP 17 2018 <br />BURNETT COUNTY <br />ZONING <br />