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i�} F'rtir, <br />Count <br />Safety and Buildings Division <br />!v <br />1400 E Washington Ave <br />Sanitary Permit Number (to be filled in by Co.) <br />' <br />P.O. Box7162 <br />�y �� I g-7� <br />Madison, W l 53707-7162 <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 />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 />oses in accordance with the Privacy Law, s. 15.04 1 m), Stats. <br />II. Application Information — Please Print All Information <br />Property Owner's Name <br />Parcel # O -7 p/:;Z ;2 y0 / �« 14 <br />` \ <br />g <br />M / t r ve A) fiJ i <br />S C, 6— CC'o i / 5 f7 V <br />Property Owner's Mailing Address Q % J %� <br />Property Location / <br />s �O <br />1 <br />/ /(J %/I/ fj r 1 <br />Govt. Lot <br />y4, Section <br />C�" it"y�, State <br />Zip Code <br />Phone Number <br />S� %� <br />�j <br />J` / <br />G .J ! L� <br />(circle one <br />T � N; R 1 E or 4v <br />11. Type of Building (check all that apply) <br />Lot # <br />Subdivision Name <br />Al or 2 Family Dwelling -Number of Bedrooms C <br />-- <br />Block # <br />❑ Public/Commercial - Describe Use <br />' <br />❑ City of <br />❑ State Owned - Describe Use <br />❑ Village of <br />CSM Number <br />_ <br />tKrown of 3 <br />HL 'Type of Permit: (Check only one box on line A. Complete line, B if applicable) <br />A' <br />❑ New System <br />ep y ❑ Replacement System <br />�&TreatmentJHolding 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 POIA7S S stem/Corn onentI 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. HDis ersalf/ reatueuent Area Information: <br />Design Plow (gpd) <br />Design Soil Application Rate(gpdsf) <br />Dispersal Area Required (sf) <br />Dispersal Area Proposed (sf) <br />System Elevation <br />Go C% <br />VI. Tandy Info <br />Capacity in <br />Total <br /># of <br />Manufacturer <br />b„ <br />Gallons <br />Gallons <br />Units <br />a ° <br />U <br />2 <br />New Tanks <br />Existing Tanks <br />y o <br />a, U <br />in y <br />ra <br />w U <br />a. <br />Sir Holding Tank <br />�j� Li <br />�— <br />UCX� <br />C' � �,� <br />J <br />Dosing Chamber <br />VIII. 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 />C <br />Plumber's Address (Street, City, State, Zip Code) <br />PO BOX 514, SIREN, WI 54872 <br />`YIIIII. Coun /IIDe artment Use Only <br />Approved <br />El Disapproved <br />Permit Fee <br />Date Issued <br />Issuing Agent Signature <br />❑ Owner Given Reason for Denial <br />IIX. Conditions of Approval/Reasons for Disapproval <br />n n <br />llv <br />Ini <br />APR 2 a '1UIU <br />Attach to complete plans for the system and submit to the t:ounty only on paper not less tuan a uz x i LacnaIn stu <br />SBD-6398 (R0313) t `_?1 n�C � Burnett County <br />f'+ Land Services Department <br />