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.;:L;:,;.T,r):;,F County pp <br /> Safety and Buildings Division P eiv'� <br /> %..,,. 1400 E Washington Ave <br /> " 9 Sanitary Permit Number(to be filled in by Co.) <br /> ' 5"i P.O.Box 7162 <br /> .' f Madison,WI 53707-7162 <br /> f• , Csc ,I Di <br /> accordanceSanitary Permit Application <br /> StateTransactionNum <br /> In with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit (0204#99 ber <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. 2Y;3/ ,cla'4 L <br /> II. Application Information-Please Print All Information <br /> Property Owner's Name / t Parcel# c2 7 C/4.3, 91,6 /.�'vz yz <br /> o 0 t/ 5 /� r 1 / Z c 5- 05- 004/ 0..� c9D c' <br /> Property Owhtlr's Mailing Address �1 Property Location/0G/ 55” <br /> C7` 5,2-3 I f '3,j e r- Lk LI Govt.Lot y / <br /> City,State Zip Code Phone Number y, %<, Section 4/ <br /> / <br /> / ( ( 5 e_ l— 4-..i..7 6-54 ?3 (circle one <br /> H.Type of Building(check all that apply) Lot# T * N; R /) E o <br /> *or 2 Family Dwelling-Number of Bedrooms 4{ d . Subdivision Name <br /> Block# h <br /> ❑Public/Commercial-Describe Use --- <br /> ❑City of <br /> ❑Stair Owned-Describe Use CSM Number ❑ Village of -- <br /> V 3 f/ t..9 ,Town of %.1.96 k.ses,t) <br /> DE.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑New System Re lacement System y � p y ❑ Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> I � <br /> i I <br /> E. 0 Permit Renewal ❑Permit Revision ❑ Change of Plumber <br /> I ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration 1 Owner <br /> W.Type of POWTS System/Component/Device: (Check all that apply) <br /> Xhlon-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> 0 Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(e(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(st) Dispersal Area Proposed(sf) System Elevation <br /> C <br /> 3 ) r 7 y/,-7 e7/5-0 A6 <br /> VI Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units P o b <br /> Ncw Tanks Existing Tanks 0 C n m <br /> n. U in . CO t -71--- <br /> Dosing <br /> ]0, <br /> Septic or Heithog T-^k / e "'. /e00 / 4/6 <br /> �, T— <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 /, l f /J 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 /> rj 4pproved ❑Disapproved <br /> Permit <br /> Fee 06 fD�atlisssue uing gent Signa e <br /> ❑ Owner Given Reason for Denial $�• '• •�~��� <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> 44 Prod j,•(W 14414st 1.e /eve i soar "44 we u. C f [1 J <br /> iii MAO ix iwSfallcSC per sit to t,H, afrect PCS Itv . -----'-� r <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x H inchesinsizeAPR 2 0 2020 } <br /> LI 1 <br /> SBD-6398(120313) <br /> Burnett County <br /> Land Services Department <br /> ,,,,,t 1e'n n n i lb( °C. <br />