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,: •`;�F �i:_r ill.: t;t." <br />County <br />-r" <br />Safety and Buildings Division <br />e—# <br />p <br />1400 E Washington Ave <br />Sanitary Permit Number (to be filled in by Co.) <br />SPS <br />P.O. Box 7162 <br />-' <br />Madison, WI 53707-7162 <br />Sanitary Permit Application <br />State Transaction Number <br />4114 <br />1 <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 />purposes in accordance with the Privacy Law, s. 15.04 1 m , Stats. <br />I. Application Information - Please Print All Information <br />Property Owner's N me <br />Parcel # O Cl - <br />r <br />Property Owner's Mailing Address <br />-7 <br />Property Location <br />f. z% ,? iA'OJ <br />Govt. Lot <br />114, 1 3 <br />/., Section <br />(circle one)— <br />City, State <br />44,-�7 <br />Zip Code <br />(/ <br />Phone Number <br />[� <br />4/5- % <br />4 <br />/ 3 <br />/�3 -z .3.Z. 7 <br />T ,6 N R j f <br />„Q(Ji <br /># <br />Type of Building (check all that apply) <br />Lot <br />SubdivisionName "a'i <br />,I.1I,. <br />fdlor 2 Family Dwelling - Number of Bedrooms / <br />Block # <br />_ <br />❑ Public/Commercial - Describe Use <br />/ <br />❑ City of <br />❑State Owned -Describe Use <br />El Village of <br />/Ifffown of N C? <br />CSM Number <br />i <br />III. Type of Permit: (Check only one box on line A. Complete line B if applicable) <br />4' <br />❑ New System <br />PI'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 />/ --V6 7 7 - %— ell <br />IV. Type of POWTS S stem/Com onent/Device: Check all that al <br />9 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 />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 # of Manufacturer <br />�,�, <br />Gallons <br />Gallons Units <br />a P _ <br />2 <br />y <br />New Tanks <br />Existing Tanks <br />a <br />5 <br />A w <br />C7 <br />ca <br />r% <br />Septic or Heldittg'Yank <br />/1 `., <br />C ( f <br />/�/� <br />L' G' X0�"— <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 Signa <br />MP/MPRS Number <br />Business Phone Number <br />WADE RUFSHOLM <br />227691 <br />715-349-7286 <br />Plumber's Address (Street, City, State, Zip Code) <br />PO BOX 514, SIREN, WI 54872 <br />V7111. Coun /De artment Use Only <br />Approved <br />Disapproved <br />Permit Fee � <br />0 <br />Date Issued <br />Issuing Agent Signa e <br />❑ Owner Given Reason for Denial <br />$ ? <br />-J 7� <br />' <br />IX. Conditions of Approval/Reasons for Disapproval <br />APPROVED DE(/0;E1V <br />Attach to complete plans for the system ano sunimt to me a,ounty omy on paper not teas man o tip w u uocn <br />SBD-6398 (R0313) n <br />AUG 0 6 2018 <br />BURNETT COUNTY <br />ZONING <br />Lk <br />�J <br />