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• <br /> ;:;las-_ .. County <br /> •. Safety and Buildings Division lielf/t;C <br /> 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> ., - ' )'I P.O. Box 7162 5444\1-.2o - 11. <br /> Madison,WI 53707-7162 -- _ <br /> CSSo(k/ <br /> - 155 <br /> Number <br /> Sanitary Permit Application StateTransaction <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 • $"'y <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. �`1 7 /� r <br /> I. Application Information-Please Print All Information e c S/ c A- u <br /> Property Owner's Name Parcel# Crj 7 0,-,76 oZ VC /6 33 <br /> 14-0C)C ) CA-r1 y/.e /5 3LR 0 23c5c,r. <br /> Property Owner's Mailing Addres Property Location tt iaBOD <br /> 6 t,;231.-, t)e wor AU& S Govt.Lot '/v r� <br /> City,State ,y► N Zip Code <br /> Phone Number/-7 �//� y, /<, Section <br /> >R/o o,n fly 4-c,tJ fl'v.• 5-5-4/;-o ? s(1/ I/5 56 (circle one <br /> ) T �U N; R /6 E W <br /> 1 II.Type of ::uni filing(check all that apply) Lot# <br /> { / 3 Subdivision Name or 2 Family Dwelling-Number of Bedrooms /� f <br /> `� Block# e 5 KA- ACh i/ <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> �/ <br /> ❑State Owned-Describe Use ..�� CSM Number ❑ Village of �- / <br /> -- -Town of 0/4 F-- //4'A'!-i <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. 1 ep <br /> I.Zt4dew System 0 Replacement System 0 Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> i <br /> B. 0 Permit Renewal 0 Permit Revision 0 Change of Plumber 0 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 appy) <br /> VI-Non-Pressurized In-Ground 0 Pressurized In-Ground ❑ At-Grade 0 Mound>24 in.of suitable soil 0 Mound<24 in.of suitable soil <br /> 0 Holding Tank 0 Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil A plication Rate(gpdsf) Dispersal Area Required(se Dispersal Area Proposed(se System Elevation <br /> 3a v / y07 f ysa 9 y .s <br /> VI.Tank Info Capacity in Total #of Manufacturer a) <br /> Gallons Gallons Units I o 0 <br /> New Tanks Existing Tanks . c E e L R m <br /> a. U i t; Co s. 0 A. <br /> Septic or HehiffE lbek /0426 —.— /Q0() / so c r uJ S<-o <br /> 1 Dosing Chamber <br /> VII. 'esponsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Pluj�b'er's Signature MP/MPRS Number Business Phone Number <br /> WADE RUFSHOLM /A/t�� 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 /> ��Approved ❑Disapproved Permit Fee Date <br /> sued /]ssmng gent Signature <br /> / <br /> /' 1 0 Owner Given Reason for Denial $31 .00 V 2020 J <br /> EX. <br /> ..Conditions of Approval/Reasons for Disapproval �/ <br /> F.�+ Rows w�ace + c cAA,t am. T-K covwers' <br /> IV Well +%est re >Oft re0 ckLc E 0 d E -11 <br /> isettra 4% be used f:r Itim ciu 6n4�' ink. <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x I.m in si;eAuG 1 8 2020 , <br /> SBD-6398(R0313) �� <br /> Burnett County <br /> Land Services Department <br /> AU..tZ17 1114 m <br />