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<;,'\e•ri; County <br /> Safety and Buildings Division ECI,"N t <br /> 1400 E Washington Ave <br /> 9 Sanitary Permit Number(to be filled in by Co.) <br /> _ <br /> , `,\1 p J"! P.O.Box 7162 Sf J'2D—151c. <br /> Madison,WI 53707-7162 r <br /> Sanitary Permit Application State42�/Tran <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit 4923193 <br /> is <br /> 193 <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 y2 9 7/3 <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. �� jj <br /> L Application Information—Please Print All information /�/Ut�—f 7�i— ..r/fJrJ kci <br /> Property Owner's Name Parcel# c 7 c/y „,Z 3s' /5—c-,5"5 <br /> A-1 <br /> Alt) K 4'1?.eti' /11,41 e-r` 0'"f- 0a2 0/7000 <br /> Property <br /> Owner's Mailing Address Property Locationp(...,/ 09•125 Z5 <br /> 7(173 /-/it/L,4c)AA} U A- 5. <br /> Govt.Lot Z <br /> City,State Zip Code Phone Number /q , <br /> �� (��t / 'A, Section <br /> �'`"!r 45e l.?'1'�OVe-- iil /t) 55-6/4 ‘12 -7,22c) -57/7/ circle on <br /> T 3 � N; R `� E iT/ <br /> ilII.Type odssilding(check all that apply) Lot# <br /> 2 Family Dwelling–Number of Bedrooms <br /> Subdivision Name <br /> Block# <br /> Public/Commercial–Describe Use ❑ City of <br /> ❑State Owned–Describe Use CSM Number q 0 Village of "� ` <br /> i V&/ 72 xr Town of LA--Fr,!/e.-/fe.- <br /> Uri.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. 1 `KNew System y ❑Replacement System 0 Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> 1 <br /> I <br /> !! <br /> B. 0 Permit Renewal I ❑Permit Revision 0 Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> ; <br /> 1 Before Expiration 1 Owner <br /> liv.Type of POWTS System/Component/Device: (Check all that apjly) <br /> i <br /> 1 ` 4Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade 0 Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑ Holding Tank 0 Other Dispersal Component(explain) 0 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 /> LfSb - -7 6 VY ,l-5.--- 15.410 <br /> VI.Tank Info Capacity in Total 4 of Manufacturer <br /> Gallons Gallons Units o 0 <br /> New Tanks Existing Tanks o e L _a m <br /> a. U in w 0 a, <br /> Septic or He}dirtgTsnle• i O Q 7Dve) ' f / i �` — <br /> DosingChamber / `l/ / <br /> VII.Responsibility Statement- .1,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 RUFSFIOLNt /, ,-J 7ys�f 227691 715-349-7286 <br /> (�C/c�GC��� /`G r <br /> Plumber's Address(Street,City,State,Zip Code) / <br /> PO BOX 514,SIREN,WI 54872 <br /> VIIIIII.CCounty/Departnlent Use Only <br /> Permit Fee Date suf Issuing A nt Sigya <br /> OP pproved 0 Disapproved $ 34,6: / /2o2o <br /> /❑ Owner Given Reason for Denial <br /> . AX.Conditions of Approval/Reasons for Disapproval ,i=" I ' 309 ' .� - <br /> , 'pa ,Nric d wwIrt be Toff Com% welt • <br /> 4 wag *awe pero+ssms .to pia min acres rood. D <br /> +a gots mut k4+- be cud (� l <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 l/2, 1 y• es n4 - 7 2020 ,' <br /> SBD-6398(R0313) l <br /> Burnett County <br /> Land Services Department <br />