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,.•,`;;tiaisTtir;�i....,. County <br /> Safety and Buildings Division <br /> re 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> P.O. Box 7162 15igrf1 —19— 1,q(P <br /> Madison,WI 53707-7162 <br /> I Sanitary Pen Application StateTransac2tionNumber <br /> lCfl <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of thus form to the appropriate governmental unit (0� 0 <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 Privacy Law,s.15.04 1 m,Stats. <br /> II. Application Information—Please Print All Information <br /> Property Owner's Name Parcel#0 7 O y;Z 3 k <br /> f,e+e ' e-1- ©co o it©o c) zt K <br /> Propert 0w er'sMailingAAddre_ss /) Property <br /> ©1-3 3 ! , G G Govt.Lot <br /> City,State lip Code Phone Number SC y, �/q, Section e� <br /> I <br /> G f g S6,v ��y�leld 13- 41.3r-ii�9 (circle one <br /> 11.Type of Building check all that apply) Lot# T N, R E ot� <br /> s l or 2 Family Dwelling—Number of Bedrooms Subdivision Name <br /> Block# <br /> ❑Public/Commercial—Describe Use ❑ City of <br /> ❑State Owned—Describe Use CSM Number ❑ Village of <br /> Town of <br /> IIII.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' ❑New System 21 Replacement 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 off P0'"ITS System/Component/Device: (Check all that apply) <br /> ❑Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑Mound>24 in.of suitable soil ;K Mound<24 in.of suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> �.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 17Y <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units n ; o <br /> New Tanks Existing Tanks c <br /> wU n , rn wC7 W <br /> Septic or4;efdfng.Task ofYQ _..,�, AD� <br /> Dosing,Chamber 600 1G,0 0 <br /> VIIII.(Responsibility Statement- R,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature r 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 /> VIIIIII.Coun /flee artment Use Only <br /> tm <br /> pproved ❑ Disapproved Permit Fee Date ssued�l C I q7/1, <br /> gen'" tore <br /> ❑ Owner Given Reason for Denial $2��' ZG �"") r � <br /> II%.Conditions of Approval/Reasons for Disapproval <br /> APPROVED <br /> Pn 0 F- 0 W I <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x m m s`(77``eEP 2019 <br /> SBD-6398(R0313) <br /> Burnett County <br /> Land Services Department <br />