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�rrsu County <br /> Safety and Buildings Division <br /> K' 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> P P.O.Box 7162 p <br /> Madison,WI 53707-7162 �A�✓C ` l�� <br /> Sanitary Permit Application State Transaction Nu ber <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of thus 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 <br /> purposes in accordance with the PrivacyLaw,s.15.04 1 m,Stats. �e,/ <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# (V 7 t7;Z67 Z <f 6 7 <br /> V;c4ori4 SigLIU c�, :2 oeo :d13011 <br /> Property Owner's MailingAddress ^� 1 Property Location1 j <br /> // +-5,4/' l v e_ SJ t�' Govt.Lot <br /> City,State j Zip Code Phone� Number �9 y� � )/4 Sectionrifiz 5/O o7� 3 q (circle on) <br /> T N; R[/6 Eo <br /> II.Type of Building(check all that apply) Lot# <br /> .(or 2 Family Dwelling-Number of Bedrooms 401_ Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use City of ` <br /> ❑State Owned-Describe Use CSM Number ❑ Village of �`- <br /> Town of <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. 9 New System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only O thet 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 1 <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(sf) Dispersal Area Proposed(sf) System Elevation <br /> 3o0 . `7 ya 5 �5- <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units r, U cb, N 2 <br /> New Tanks Existing Tanks o <br /> a , in s C7 0. <br /> Septic or look t[tgl-M <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 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 /> VIII.Coun /De artment Use Only <br /> Approved ❑ Disapproved Permit Fee <br /> 00 QDate Issu swn gent Signature <br /> ❑ Owner Given Reason for Denial $ J T7. `� �� �' G <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> APPROVED <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 in <br /> AUG 2 1 2019 <br /> SBD-6398(R0313) tle <br /> Burnett County <br /> Land Services Department <br />