Laserfiche WebLink
County <br /> ,.• Safety and Buildings Division ��t/rA.% 9- <br /> ® 'K` 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> D. <br /> I "I P.O.Box 7162 j� <br /> s Madison,WI 53707-7162 <br /> �T tr" �3 <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 (4206 4 d- <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. ., A).1I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# O 7 0 2 y a 3 9 1 y v?C`.. <br /> --SC) e-_- 1/4-7//or / a i o a � ttKo0�1`� <br /> Property Owner's Mailing Adds Property Location Q <br /> ei7jf(�6 //0#1 -5-f / Govt.Lot / <br /> City,State Zip Code Phone Number �)C /� 1i ,2 e <br /> �2 /,, Section <br /> M evil 1-i ce /C /7,,�} !`(circle one <br /> / s'� 3 T T . 7 N; R /T E ori! <br /> II.Type of Building(check all that apply) Lot-61or 2 Family Dwelling-Number of Bedrooms -- Subdivision Name <br /> —_— <br /> Block#______ <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> CSM Number 0 Village of <br /> ❑State Owned-Describe Use <br /> --- ..Town of Je u 5 ic <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. XNew System 0 Replacement System 0 Treatment/Holding Tank Replacement Only Other Modification to Existing System(explain) <br /> B. CIPermit 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 POWTS System/Component/Device: (Check all that apply) <br /> Non-Pressurized In-Ground ❑ Pressurized In-Ground 0 At-Grade ❑ Mound>24 in.of suitable soil 0 Mound<24 in.of suitable soil <br /> ❑ Holding Tank ❑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 /> 30 v , 7 92`j 4f--o -5---- <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units i o'' 0 <br /> New Tanks Existing Tanks 0 o 2 i 5 ro <br /> e.. U v] H co ir. C7 o.. <br /> Septic or 13akL g T k 7 A1 <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 ) .0"-- 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 /> �pproved ❑ Disapproved Permit FeeDate ssu I Agent Signa e / <br /> 315 d 9 2019 - _ <br /> ❑ Owner Given Reason for Denial / <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> ho,-- ,,_,,— <br /> 1EillEINIE - <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 t/2 x 11 inches <br /> SBD-6398(R0313) SEP 2018 ,..)' !, <br /> Burnett t Cunty <br /> Land Services Department <br />