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County <br /> Safety and Buildings Division /^A)e- <br /> (� 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> P.O. Box7162 44 - lcl-32. 61 Lf'31 J <br /> Madison,WI 53707-7162 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate govermnental 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.15.04 1 m),Stats. g 7✓ � 61/ye'l exrg LAJ <br /> I. Application Information—Please Print All Information <br /> Property Owner's Name\ Parcel# a 7 &� 4/O <br /> C LIf-� Si7j i//j bo& O/Y000 <br /> Property Owner's Mailing <br /> l Address Property Location <br /> O t:/c-!7 tr C , Govt.Lot <br /> City,State Zip Code Phone Number /4, %4, Section <br /> r A k �//() � (circle one <br /> T N; R��_E o� <br /> II.Type of Building(check all that apply) Lot# <br /> f'Sl 1 or 2 Family Dwelling—Number of Bedrooms � D Subdivision Name <br /> Block# <br /> ❑Public/Commercial—Describe Use <br /> ❑City of <br /> ❑State Owned—Describe Use CSM Number ❑ Village of <br /> Town of /,/i'U i'rn11� <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑ New System Y.Replacement System g p Y g Y (explain) <br /> C111 ❑ Treatment/Holdin Tank Replacement Only ❑ Other Modification to Existing System <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.T e of POWT ;system/Component/Device: Check all that a I <br /> Mon-Pressurized In-Ground ❑ Pressurized In-Ground El At-GradeElMound>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) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> y5-d 413 6 5 a ylg <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units <br /> New Tanks Existing Tanks y .n <br /> 0 <br /> rs. U <br /> Septic or llehling"Pank O a v D 0 <br /> Dosing Chamber O > t_/ U <br /> VII.Responsibility Statement-- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) PlumberSignature MP/MPRS Number Business Phone Number <br /> 227691 <br /> WADE RUFSHOLM �fp�/ 227691 715-349-7286 <br /> i <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 <br /> VIII.Court /De artment Use Onl 1 <br /> Approved ❑Disapproved Permit Fee Date Issued Issuing Agent S' ture <br /> ❑ Owner Given Reason for Denial <br /> IX.Conditions of Approval/Reasons for Disapproval 3 s C�C, <br /> C CE ON E <br /> Attach to complete plans for th so ' the County only on paper not less than 8 1/2 x 11 h size I 2019 <br /> SBD-6398(R0313) / 713� <br /> Burnett County <br /> y )2r/l q Land Services Department <br />