Laserfiche WebLink
County <br />-; <br />Safety and Buildings Division <br />1400 E Washington Ave <br />Sanitary Permit Number (to 1— filled in by Co.) <br />. <br />P.O. Box 7162 <br />Madison, WI 53707-7162 <br />q <br />N-l9`1 bq 4 J `f / �3 <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 />the Department of Safety and Professional Services. Personal information <br />Project Address (if different than mailing address) <br />you provide may be used for secondary <br />m oses in accordance with the Privacy Law, s. 15.04 l m , Stats. <br />p d <br />12Y" G7 7 G oq (z-�, <br />R. Application Information-- Please Prink All Information <br />Property Owner's Name <br />f. <br />,-AJ <br />Parcel # Q 0/3 a 916 3 <br />/yam <br />/ f <br />r5� <br />Property Owner's Mailing Address <br />Property Location <br />Govt. Lot <br />%a, Section <br />City, State <br />Zip Code <br />Phone Number <br />lrcle one <br />T � N; R � E ot� <br />11. Type of building (check all that apply) <br />Lot # <br />Al or 2 Family Dwelling — Number of Bedrooms 6;� <br />Subdivision Name <br />Block# <br />Public/Commercial —Describe Use <br />❑ City of <br />❑ State Owned - Describe Use -"` <br />❑ Village of <br />CSM Number <br />V1� <br />Town off .ti Esc J <br />III. Type of Permit: (Check only one box on line A. Complete line B if applicable) <br />A. <br />w 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 of POWTS S stem/Co1n onent/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 />❑ Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain) <br />V. Dis ersa➢/Treatanent 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 />00 <br />7 <br />y <br />y5-6) I9�- <br />y <br />VI. Tank Info <br />Capacity in <br />Total <br /># of <br />Manufacturer <br />Gallons <br />Gallons <br />Units <br />fl <br />w C <br />o <br />u <br />D <br />N <br />New Tanks <br />Existing Tanks <br />o <br />a U <br />m Z; <br />;3 <br />i% C7 <br />a <br />Septic orAoid ng`Faek <br />Dosing Chamber <br />Wl. Responsibility Statement- 1, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. <br />Plumber's Name (Print) <br />WADE RUFSHOLM <br />Plumber's Signature <br />/ ) <br />MP/MPRS Number <br />227691 <br />Business Phone Number <br />715-349-7286 <br />Plumber's Address (Street, City, State, Zip Code) <br />PO BOX 514, SIREN, WI 54872 <br />Wn. Count /De artment Use Onl <br />Approved <br />❑ Disapproved <br />$e J7J <br />J J <br />Date Issued G <br />Issuing Agent Signature <br />❑ Owner Given Reason for Denial <br />��2 �� / <br />�/. <br />IIX. Conditions of Approval/Reasons for Disapproval }� % — /ADk A <br />call,g7o � <br />APPROVED CE0VE <br />Attach to complete plans for the syste and submit to the Co my only on aper not less than 8 1/2 x <br />to in size <br />JUL 12019 <br />Sl3I)-6398 (R0313) <br />Burnett County <br />Land Services Department <br />