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Ywrr r Count <br /> Safety and Buildings Division cr ('A) e. <br /> ft <br /> 4/ �, 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> ' \ ' <br /> ` P.O.Box 7162 SAVQ_ <br /> /` " 20 2/D <br /> Madison,WI 53707-7162 _ <br /> -F,;,:,, , CST- .f.D- l9 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit YL v"�� � <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 /> I. Application Information-Please Print All Information <br /> Property Owner's Name ff Parcel# 07 n/,,2 2 elD l5 /o <br /> A--/J J! A-6h//A /.. ' /a9 a9.2eae) <br /> Property Owner's Mailing Address Property Location 0 6915 <br /> p2 /7 D e-e-f p� W/V Govt.Lot <br /> City,State / Zip Code Phone Number y, %a, Section `0 <br /> 4)' ' et t-i b)X <br /> 5 4/g.50 (circle one <br /> III.Type of Building(check all that apply) Lot# <br /> , <br /> f 71-4--or3 r 2 Family Dwelling-Number of Bedrooms _? .3 Subdivision Namel <br /> Block# bE?er,p . MU /9.cIJ. 10 /��/{�•'/ <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> 0 State Owned-Describe Use CSM Number ❑Village of <br /> r.-- Town of 3fil c k e,/J <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> 0 New System 0-Replacement System ❑ Treatment/Holding Tank Replacement Only 0 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 POW'I'S System/Component/Device: (Check all that apply) <br /> jion-Pressurized In-Ground 0 Pressurized In-Ground ❑ At-Grade 0 Mound>24 in.of suitable soil 0 Mound<24 in.of suitable soil <br /> ❑ Holding Tank 0 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 /> 1/5-0 < .7 6 V 0 -s-© ?Y,s <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units . ° o 0 <br /> .g New Tanks Existing Tanks 2o 7.) m <br /> a. U cn . o w C7 a, <br /> Septic or ielliinefanic /Ot' 0 /OLO / /,) Cr^w c-S"c "./..— <br /> Dosing <br /> `Dosing <br /> 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 RUFSHOLIVt /_ f 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 /> roved ❑ Disapproved Perrmmit Fe Dat Issu ng gent�i e <br /> v <br /> 0 Owner Given Reason for Denial $✓• ��� �— <br /> IX.Conditions of Approval/Reasons for Disapproval 7 _ <br /> Id Di&4KAS wcust be keel, l 4g' <br /> Olt seem, to be febtAotPeot per aU state) Gou,4441, IIECEDVE1Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 1in size <br /> 6'1AR 2 l 2020 <br /> SBD-6398(R0313) <br /> Burnett County <br /> Land Services Department <br />