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1i Rrtr_r'�.., County <br /> i<:,...:,. • Safety and Buildings Division A y ridL <br /> , '., 1400 E Ave <br /> WashingtonSanitary Permit Number(to be filled in by Co.) <br /> ' =i P.O. Box 7162 91W..2a -b/o <br /> Madison,WI 53707-7162 <br /> Sanitary Permit Application StateTransactioonnN�um{ber <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit Gat h//�+ <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. I—� y ��'p� <br /> I. Application Information-Please Print All Information V <br /> Property Owner's/NI.me Parcel# c 7 04/0 2 3.7 11 3y <br /> •�L0 S rely a vi6,,, c e o 0 <br /> Property Owner's Mailing Address/ t Property Location / <br /> i; 57O/ jiorl-qq/Ai i Govt.Lot <br /> City,State ZipCode <br /> 1,� Phone Nuumbeer �J 1/4,4) 1, Section .y <br /> G f iL1-5 �Gf l-,C /� _ / �/ 0 5163 -3Y.��3 j N; (circle one) <br /> /Ttv J ) T �7 y N; R /7 Eotle <br /> U.Type of Building(cbels all that apply) Lot# <br /> or 2 Family Dwelling-Number of Bedrooms 4:72. Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use ❑ City of <br /> CSM Number ❑ Village of '_- <br /> ❑State Owned-Describe Use '. ( Town of ), /12/9-1‘51A//9i✓t7/ <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> ❑New System XR.eplacement System 0 Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. 0 Permit Renewal 0 Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POVVTS System/Component/Device: (Check all that apply) <br /> VcNon-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 /> 3o 0 , 7 5/a y �'�.--e, 7 <br /> VII.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units ° ,,, <br /> New Tanks Existing Tanks v g2 'd L a 1 m <br /> a.U rn v, v, w a G, <br /> Septic or N3eldirtrank S'j C J® OVO ` 6 /( f e. x <br /> Dosing Chamber (3J 7D 0 - Sb' / `�`' / !� <br /> VII.Responsibility Statement- II,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 <br /> a --11.------ 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 <br /> VIII.County/Department Use Only <br /> proved 0 Disapproved Permit Fee$3?5• 06 3g2.a2D Date su gent Sign e / <br /> ❑ Owner Given Reason for Denial <br /> IX.Conditions of Approval/Reasons for Disapproval /oa• / 1�,r✓ <br /> 2t ,�IWa.4ibW% IMO b t MA owe f Q 4,04( 7 ili <br /> r �(�� <br /> 4t t c'vt 0( KAItst bt k vtilin, E © E, Q V E 1 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 , in VAR ^ 2020 <br /> ......J \ <br /> SBD-6398(R0313) <br /> Burnett ounty <br /> Land Services Department <br />