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/fly ART feyl, County l I <br /> Safety and Buildings Division O U E'— <br /> fr ; <br /> $ ; 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> P.O. Box 7162 <br /> \ \ PS. Madison,WI 53707-7162 <br /> �srQ'NM1�' Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 38321(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 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_ 1 m,Stars. <br /> L Application Information-Please Print All Information <br /> Property Owner's Name Parcel# O 7 D r{O -2 30 <br /> 141 A)1Zs 03 006 - Oa 020 <br /> Property OwnnWs Mailing Address Property Location a o <br /> 6 O I P C4 Govt Lot <br /> City,State 1 Zip Code Phone Number Sin �, s E v,, Section YO <br /> Gr,h 574vr w,� 55/85/IU 15' /8 �S5 5 (circle one <br /> T�N; R�Eo�r <br /> Ix Type of Buildi (check all that apply) Lot# <br /> Al or Family Dwelling-Number of Bedrooms �2 Subdivision Name — <br /> Block# <br /> ❑PubliclCommercial-Describe Use <br /> ❑City of <br /> CSMNumber ❑Village of / A <br /> ❑State Owned-Describe Use - WTov m of Al e-5 74- /�Rrs/40 4 <br /> III.Type of Permit: (Check only one box on line A- Complete line B if applicable) <br /> A. ❑New System ❑Replacement System KTreatmentlHolding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> ff List Previous Permit Number and Date issued <br /> B. ❑ Permit Renewal ❑Permit Revision ❑Changeomumber El Perna <br /> Before Expiration Owner <br /> l V.T of POWTS S m/Com onent/Device: Cheek all that apply) <br /> ❑Non-Pressurized In-Ground ❑Pressurized 1n-Ground ❑At-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 in_of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Devitt(explain) <br /> V.Dis ersaVrreatment Area Information: <br /> Design Flow(mod) Design Soil Application Rate(gpdst) Dispersal Area Required(St) Dispersal Area Proposed(st) System Elevation <br /> 3o v <br /> VI.Truk Info Capacity Ain Total #of Manufactmer o <br /> Gallons Gallons Units <br /> New Tanks <br /> Exit gTanks m ='• i p <br /> n.U rn q rn ia.C7 P. <br /> septic oo �tJorty s <br /> Dosing Ch=W <br /> VIL Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/h1PRS Number Business Phone Number <br /> WADE RUFSHOLM 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) (/lf <br /> PO BOX 514,SIREN,WI 54872 <br /> CountyMepartment Use Only <br /> XApproved ❑Disapproved Permit Fee O Da/t�e issued Issuing Agent Signature <br /> ❑Owner Crtveo Reason for Denial $ ��� /- �^ / 7 <br /> UL Conditions of Approval/Reasons for Disapproval <br /> E*CEI <br /> Atdch to complete WAXES for We system and submitte the County only on papa oot less than 8 In I. <br /> es <br /> -_-_-. BURNETTCOUNTY <br /> ZONING <br />