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Attach to complete plans for the system and submit to the County only on paper not less thAUG 15 2018 11 inches in size <br />SBD -6398 (R0313) Irl <br />BURNETT COUNTY <br />ZONING <br />COUIIty <br />- �; • <br />Safety and Buildings Division��til <br />' G <br />p S <br />1400 E Washington Ave <br />Sanitary PermitNumber(to be filled in by Co.) <br />l P $ If! <br />P.O. Box 7162 <br />Madison, WI 53707-7162 <br />Sanitary Permit Application <br />State Transaction Number <br />19 O 1 <br />In accordance with SPS 383.21(2), Wis. Adm. Code, submission of thus form to the appropriate governmental unit <br />J <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 PrivacyLaw, s. 15.04 1 m , Stats. <br />y�.. <br />I. Application Information — Please Print All Information <br />Property Owner's N;e p <br />Parcel# 0 -7 / 7 37 �(Q /9 i <br />/2✓1� 1 �� T 4�s14 <br />0 0 <br />Property Owner's Mailing Address <br />/ <br />Property Location �C <br />_ <br />7 Y �� �G' <br />/ 1-dC� /� <br />Govt. Lot <br />1/., ! f <br />�: n. � /., Section <br />city, <br />Ci St46f�EL <br />Zi Code Phone <br />P <br />Number <br />' j T <br />r (/� T <br />7 /> <br />T� 1 N, R circle onei�. <br />II. Type of Building (check all that apply) Lot <br /># <br />Name <br />❑Subdivision <br />1 or 2 Family Dwelling— Number of Bedrooms <br />ublic/Commercial Use Block <br />',Public/Cial Dbe U <br />'P,,.,{ Describe — <br /># <br />/I ,' <br />❑ City of � <br />❑State Owned —Describe Use CSM <br />�— <br />El Village of <br />Number <br />r-- <br />Town of <br />11I. Type of Permit: (Check only one box online A. Complete line B if applicable) <br />A. <br />$New System <br />❑ Replacement System <br />❑ Treatment/Holding Tank Replacement Only <br />❑ Other Modification to Existing System (explain) <br />B. <br />❑ Permit Renewal <br />❑ Permit Revision <br />❑ Change of Plumber <br />❑ Permit Transfer to New <br />List Previous Permit Number and Date Issued <br />Before Expiration <br />Owner <br />IV. Type <br />of POWTS System/Component/Device: Check all that apply) <br />❑ Non -Pressurized In -Ground ❑ Pressurized In -Ground ❑ At -Grade A Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil <br />❑ Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain) <br />V. Dispersal/Treat ent Area Information: <br />Design Flow(gpd) <br />Design Soil Application Rate(gpdsf) <br />Dispersal Area Required (sf) <br />Dispersal Area Proposed (sf) <br />System Elevation <br />X700 <br />0 C) <br />690 <br />9 : <br />VI. Tank Info <br />Capacity in <br />Total <br /># of Manufacturer <br />c <br />Gallons <br />Gallons <br />Units <br />a <br />RS U U U F. N <br />New Tanks Existing Tanks <br />y o <br />a U <br />Septic or HoidiagTank <br />v <br />Dosing Chamber <br />Ze2B� <br />VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. <br />Plumber's Name (Print) <br />Plumber's Signature <br />MP/MPRS Number <br />Business Phone Number <br />WADE RUFSHOLM <br />/ <br />227691 <br />715-349-7286 <br />Plumber's Address (Street, City, State, Zip Code) <br />PO BOX 514, SIREN, WI 54872 <br />VIII. Coun /De artment Use Only <br />Approved <br />❑ Disapproved <br />Permit Fee <br />vp <br />Date Issued <br />Issuing Agent Signature <br />$,37,S— <br />Q� <br />—� <br />El Owner Given Reason for Denial <br />V U <br />IX. Conditions of ApprovalMeasons for <br />DisapprovalP <br />PGO/` yilYl'C O �/t�/�✓O!/AcL. <br />G�NA� <br />}� F /✓V UvC �" ON <br />t <br />R rt VE D <br />U <br />:t nr) EuMVE[F)) <br />Attach to complete plans for the system and submit to the County only on paper not less thAUG 15 2018 11 inches in size <br />SBD -6398 (R0313) Irl <br />BURNETT COUNTY <br />ZONING <br />