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4ar i.� County / t <br /> f, Safety and Buildings Division <br /> 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> P.O.Box 7162 54/J <br /> Madison,WI 53707-7162 <br /> Sanitary <br /> Permit Application State TrannpsactionNumber <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit "131�_ <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]nailing 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. <br /> I. Application Information—]Please Print All Information <br /> PrKerty ,wr-e_ <br /> Owner's Name Parcel# 0-7®,3 C .9 e& /`7 iZel <br /> IV OI'c le� -d,250f0 <br /> Property Owner's Mailing Address Property Location <br /> 4 61— 6,) A ogt, Govt.Lot <br /> City,State t Zip Code Phone Number y4, %4, Section <br /> S /v 1 Cv--r 53?. o �o p l?3,7 u7 0 • N; RUE t U(circle one <br /> _ o <br /> II.'type of Building(check all that apply) Lot# T� <br /> V4 or 2 Family Dwelling-Number of Bedrooms 3 Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use --^ ❑ City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> i ; ///p �� �Town of /►J/O!tJ <br /> 111.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A, ❑New System -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 /> ICI.Type of POVVTS System/Component/]Device: (Check all that a ➢ <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.Dis ersal/7rreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 7 6 11-3 5 <br /> VI.Tank Info Capacity in Total #of Manufacturer � <br /> Gallons Gallons Units o <br /> New Tanks Existing Tanks o B y .2� 5 <br /> Septic or fI@kMg,_apk Q,r7�l -�- A00 (05 G <br /> Dosing Chamber <br /> 'tVII.Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POW'TS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> WADE RUFSHOLM (I��+�J 227691 715-349-7286 <br /> ru <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 <br /> III.Count /lDe artn4ent Use Only <br /> pproved El Disapproved <br /> Permit Fee DZte �s�ue�d I ng gent Si ture <br /> ❑ Owner Given Reason for Denial $ OD I /9 1 L � <br /> IX.Conditions of Approval/Reasons for]Disapproval �(�J 11,�iC <br /> APPROVU <br /> fR <br /> � 6E�0 <br /> VTI' <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x ) n ins-OCT 23 <br /> 39 <br /> 2 <br /> SBD-6398(R0313) t3 7 <br /> Burnett County <br /> Land Services Department <br />