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County <br /> -` '�'• Safety and Buildings Division ,C?q/►ti C?� <br /> 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> P.O.Box7162 5'AIJ -(Gj-1 47 <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 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 3 C i Sz <br /> purposes in accordance with the Privacy Law,s.15.04 1 m,Slats. Q J <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# O'7 ©` 2 2 <br /> Property Owner's Mailing Address Property Location <br /> f6 a J Govt.Lot <br /> City,State Zip Code Phone Number y, y,, Section oG J <br /> i _ <br /> Q j �ff� �� �� r (circle one) <br /> [� T Y R!� Eo g <br /> II.Type of Buildin (check all that apply) Lot# <br /> A'1 or 2 Family Dwelling-Number of Bedrooms Subdivision Name Block# /'S,"^ `t/t-d s e!f <br /> /n A Z e,0,4 w e� <br /> ❑Public/Commercial-Describe Use ❑ City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of <br /> -,A-Town of SE�Jl$ S <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑New System F4eplacement System ❑ Treatment/Holding Tank Replacement Only ❑ 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 /> IV.Type of POWTS System/Component/Device: Check all that a 1L. <br /> V411on-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 ersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units c <br /> New Tanks Existing Tanks y o i <br /> n. U in on <br /> Septic or•Heidnn ank 0?006 v ee)[-) -2- c- 0 <br /> Dosing Chamber <br /> VII.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 A MP/MPRS Number Business Phone Number <br /> WADE RUFSHOLM / l _ (/ 227691 715-349-7286 <br /> rs-- <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 <br /> VIII.Coun /De artment Use Only <br /> Approved ❑ Disapproved Permit Fee DQate slLjued q ruin Agent Si afore <br /> ❑ Owner Given Reason for Denial J / ( �� 06 <br /> IX.Conditions of ApprovaVReasons for Disapproval — <br /> ► (W C5PK MA&S+ Ix rdC-r6((A Showirtq bfS act CO%bltltc(, <br /> with in 3o dfif 6' sek*lr' k5fa I(C-If6K, n [Firi q gniq <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 i in size <br /> SBD-6398(R0313) Burnett County <br /> Land Services Department <br />