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County <br /> Safety and Buildings Division e-7 t <br /> 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> P.O. Box 7162 --k)_ <br /> 4 a Madison,WI 53707-7162 <br /> State Transaction Number <br /> Sanitary Pe t Application &28321i <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit <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. `T 1 <br /> 1. Appilication Information-Please Print All Information .5 74/ 15 /t i <br /> Property Owner's Name Parcel# -7 7/9;2 J <br /> Property Owner's Mailing Address Property Location �4��5 <br /> ,46,>r, Z6 Govt.Lot <br /> City,State Zip Code Phone Number y, /4, Section vZ 7 <br /> ��I'/ C v✓ 5��3 �}����j-" a2�6 (circle one <br /> T��N; R/3 E W <br /> H.Type of iSuRding(check a➢➢that applly) Lot# <br /> or 2 Family Dwelling-Number of Bedrooms � � Subdivision Name <br /> p <br /> Block# �//?�/le-Sd� ! A r� <br /> ❑Public/Commercial-Describe Use �^ r- ❑City of <br /> CSM Number El village of 'f <br /> ❑State Owned-Describe Use <br /> ----- Town of <br /> 111.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑ New System 5irBeplacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> 19. ❑ Permit Renewal ElPermit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> Iv.Type of POWTS System/Component/Device: (Check all that apply) <br /> ❑Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> P�-Zotding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Di5 ersall/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(so Dispersal Area Proposed(so System Elevation <br /> v1.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units a ?: <br /> U <br /> New Tanks Existing Tanks v c °y a ..�°3 .2�° � <br /> aU n ra w'C7 a <br /> 6epw1t,r Holding Tank >6r�d �OC� <br /> Dosing Chamber <br /> VH.ReSp®uu5ibi➢ity StateMent- 17 the undersigned,assume responsibility for installation of the iPOWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature ^r�s� MP/MPRS Number Business Phone Number <br /> WADE RUFSHOLP/I / 1 � 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) GAL/ <br /> PO BOX 514,SIREN,WI 54872 <br /> v11II.County/De artment Use Only <br /> Tel�� <br /> �­ <br /> -j:(n7CondjfionsDate ssued ss gent Sign e <br /> Approved ❑Disapproved <br /> ❑Owner Given Reason for Denial .�Za <br /> of Approva➢/Remsons for Disapproval <br /> o�If,+ (r prescwf) MAO �k ed; s�t� Per sus. 3g3 _� 3b3 -- 3-�5 <br /> F�ot�,,' TaHk Mum loc > 2Sff4..malt Was. D"16e <br /> it <br /> ���y�,I` / Attach to complete plans for the system and submit to the Cou'hty only on paper not less than 8SBD-6398(R0313) Q <br /> Burnett County <br /> Land Ser,ices Department <br />