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rsu Count <br /> Safety and Buildings Division <br /> 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> P.O.Box 7162 1 <br /> Madison,WI 53707-7162 <br /> Sanitary Pe it Application 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 PO WTS 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,Slats. 0�11107,2 �4rr,,,,j S � r: <br /> 1. A lication Information-Please Print All Information <br /> Property O.wner's Name 1 Parcel# O 7 ; 3 <br /> �..I`�) ©lS ON 5- /5" 41 7A 03 OOC'U <br /> Property Owner's Mailing Address ^^ Property Location 1 <br /> A Q Q, l i S Govt.Lot 1' <br /> City,State Zip Code Phone Number y4 <br /> /<, Section <br /> f� /� t 15Y127 <br /> /�/ 9/GJ . '/(circle one/BONA/ /nnc 7 Z��N; R�12_EoC <br /> IIII Type of Baui➢diung(check all that apply) Lot# <br /> or 2 Family Dwelling-Number of Bedrooms <br /> a, 1"o <br /> Block# 5.5e5--5-0 f <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number El Village of ) <br /> Town of /n e'e'o CMA <br /> —a- <br /> III.Type of Permit: (Check only one box on line A. Complete wane B if applicable) <br /> A. <br /> ❑New System Replacement System ❑ Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <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 /> TV.Type of POWTS System/Component/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.IIDis ersallTreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> VL Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units °o <br /> New Tanks Existing Tanks <br /> w U m h n r2 <br /> Septic or u^�T--'- �J(f G L�Q <br /> Dosing Chamber .� [O V `� ✓Ot� <br /> III.Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWT'S shown on the attached plans. <br /> Plumber's Name(Print) PI b ' Signature MP/MPRS Number Business Phone Number <br /> WADE RUFSHOLM 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 <br /> YT111.Coun /aDe artment Use Only <br /> pproved ❑ Disapproved Permit Fee Date Issu�Z Is g t <br /> ❑ Owner Given Reason for Denial $ i' 7'. �VIE <br /> kl�AIX.Conditions of Approval/Reasons for Disapproval <br /> APPROirn MAY 2 8 2019 <br /> V 11 U BURNETT COUNTY <br /> Attach to complete plans for the s o unty only on paper not less than 8 1/2 x c . ze <br /> SBD-6398(R0313) /�3'�QGf�/ <br /> -if I <br />