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i ;i iwrti+; County n <br /> '.' ,[ <br /> , Safety and Buildings Division 5 ti- 7^/t l� <br /> � Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> c,� t'. 1400 E ap 1- 50 i P.O.Box 7162 ,31 " oa_ <br /> • :?` '; .. .__ :,'' Madison,WI 53707-7162 <br /> ++ <br /> L 3/ y37 <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 <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 3 , 5,/..;5"- <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. <br /> I. Application Information-Please Print All Information C-4 ,e <br /> Property Owners Name / Parcel# •7 c"1/y o7 3 e/5 2 C <br /> �..J o f/t /} b O e --FS col.- / a/ (a 00 o//coo <br /> Property Owner's Mailing Address Property Location # eq 7 4` <br /> /3 4/Ci /41-4 i''e rd Govt.Lot / J <br /> City,State i Zip�Coode Phone Number 2 ��/< Ale-/, Section a e <br /> { //Id 0A) m).c 5-7o o/"C (O -5/.75 3 J 1-7ZFsircle one <br /> II.Type of .:uilding(check all that apply) Lot# T j N; R /� E o vv <br /> pg.4.or 2 Family Dwelling-Number of Bedrooms ,/ Subdivision Name <br /> Block# <br /> �^ <br /> ❑Public/Commercial-Describe Use .------ <br /> 0 City of <br /> ---' CSM Number 0 Village of <br /> ❑State Owned-Describe Use ,...„ ,.,/ ,i. <br /> r- 91 Town of I.-4 c e-tr <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> 0 New System rit Replacement System 0 Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> B. 1 0 Permit Renewal ❑ Permit Revision 0 Change of Plumber 0 Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> FV.Type of P+li WTS System/Component/Device: (Check all that apply) <br /> jg-Non-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) ❑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 /> o,oo ; 7 Ps-.9 5,--e,„ <br /> c) 957 7 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units <br /> U <br /> 0LY <br /> New Tanks Existing Tanks o „, 6y 0 6 <br /> e. U co m cn z. CD a, <br /> Septic orlde' SDU �`,0 a2 /3c ,t'rie5c-e --1/44%,/74- <br /> 4- -A- <br /> Dosing Chamber <br /> SII.Responsibility Statement- 11,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's SignatureMP/MPRS Number Business Phone Number <br /> WADE RUFSHOLM f , v///”`/_/��o✓ 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) �f�' <br /> PO BOX 514,SIREN,WI 54872 <br /> VIII.County/Department Use Only <br /> X.Approved 0 Disapproved Permit Fee Date Issued Issuing Agent Signature <br /> $ 37c — /—//-zi 4). A <br /> ❑ Owner Given Reason for Denial <br /> 1 IX.Conditions of Approval/Reasons for Disapproval /Cc. <br /> - .-1_c23 3 75 <br /> TD <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 11 i des in JAN U 8 ZUZ1 j - <br /> SBD-6398(R0313) <br /> Burnett County <br /> Land Services Department <br />