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Isaru�yr County <br /> 01 <br /> Safety and Buildings Division BURNETT <br /> 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(m be filled in by Co.) <br /> Madison,WI 53707-7162 <br /> �raan��� Ss8 8 88 <br /> Sanitary Permit Application State ran sact on Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this fort to the appropriate governmental unit IW <br /> is required prim 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 Servies. Personal minnow"you provide may be used fm secondary <br /> purposes in accordance with the Privacy Law,s. 15.04 1 m,Stats. 57-3 7-3 C �� <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name // DO ores U/Wetlrng 666 Parcel# O 7-a -a•�!/-�s=.fib'-� <br /> 2057 6. 6-dr4e NadjSj 0-2-ono — 030 <br /> Property Owner's Mailing Address Property Location 0 <br /> ao r o s Per GoVt-tMI- <br /> City,State / Zip Code Phone Number yy��%, Section 07� <br /> f} 2 EJ o o In n) S std G is -72� X 5 73 (circle one) <br /> Lot# <br /> Il.Ty6e of Building(check all that apply) T_YL_N; R /S E o® <br /> It or 2 Family Dwelling-Number of Bedrooms ,3 Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use -- ❑City of `-- <br /> D State Owned-Describe Use CSM Number El Village of�or r <br /> 7 ATn Owof 6- Sc.v.s,s <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) - a,a <br /> A. ❑New System Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal �❑` Pemnit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS S em/Com onent(Device: Check all that apply) <br /> ANon-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Ciradc ❑Mound>24 in.of suitable soil ❑Mound<24 m.of suitable soil <br /> ❑ Holding Tank ❑Older Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Drspersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 7 6 V-3 6 sd ys, 60 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units <br /> New Tanks Existing Tanks <br /> U ran .., h i-w V G <br /> Septic or Holding Tank 7 6 7-5-0 15-6 6 p2 C.In C <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 Cade) <br /> P.O.BOX 514,SIREN WI 54871 <br /> VIIIL County/Department Use Only <br /> k Approved 11 Disapproved Permit Fa Date issued Issuing igneture <br /> ElOwner Given Reason for Denial f '�LZ5 <br /> DL.Conditions of ApprovaMeasous for Disapproval M <br /> $o,! A6wv/61rM -. CGU Is A�QCAM & A It-6jIMln9 W411, but IS > /o 'Ee ADECSI <br /> V(� <br /> Rauhtommal mWawfortheseatemsed aebmn to the coonoehwweer antlm Wasvta 0�1 22 2017utm <br /> BURNETT COUNTY <br /> ZONING <br />