Laserfiche WebLink
County <br /> Safety and Buildings Division <br /> 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> P.O. Box w, vA�(Madison,WI 53707-7162 - t9, -130 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of thus form to the appropriate governmental unit `*'t q 1'"Q 9 <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 I m,Stats. <br /> II. Application Information-Please Print All Information / /7 <br /> Property Owner's Name Parcel#®7 p`j,;? <br /> J�(' ` <br /> 00 daoanc���I�{}0 <br /> Property Owner's Mailing Address Property Location �C7 <br /> (Ca 6 7 t`G Govt.Lot 1Z <br /> City,Sta Zip Code Phone Number <br /> /4, /4, Section <br /> SL D `>✓�� �j y�� 1-713— �,7�'�� (circle one <br /> T �/ N; R f 5— E o(Vv <br /> H.Type of Building(check all that apply) Lot# <br /> t1c1 or 2 Family Dwelling-Number of Bedrooms 11 Subdivision Name <br /> - Block# <br /> ❑Public/Commercial-Describe Use --�"' ❑City of <br /> ❑State Owned-Describe Use <br /> �^ CSM Number ❑ Village of <br /> i <br /> ;ErTown of r✓✓/�S <br /> 111.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> ❑New System Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> 13. ❑ 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]POWA'S 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.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(st) Dispersal Area Proposed(sf) System Elevation <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units L o b <br /> New Tanks Existing Tanks o Y p 2 m <br /> Septic or a 1T-' <br /> 9p o <br /> Dosing Chamber <br /> VII.Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's 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 /> 57III.Fount /lDe artment Use Only <br /> JE(Approved ElDisapproved Permit Fee Dat/30 <br /> ssued Is ng gent Sig e <br /> 00 <br /> El Owner Given Reason for Denial $ �' / L9O <br /> 11 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> APPROVED C,�AY4,q-73 3 7 <br /> nn <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 7 Ffffhl hes in size <br /> SBD-6398(R0313) IR JUL 3 0 2019 �• ` <br /> Burnett County <br /> Land Services Department <br />