Laserfiche WebLink
i ,:,,R. 1 i f_ County , r <br /> Safety and Buildings Division , c/j'` t', <br /> ,,' 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> ' `,ti H <br /> , , P.O.Box 7162 P1J .221. <br /> f; ..._._...r< Madison,WI 53707-7162 <br /> Z-- -8.3$3 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit <br /> is required prior to obtaining a sanitary permit. Note:Application forms for state-owned POWTS are submitted to Project Address(if different than mailing address) <br /> the Department of Safety and Professional Services. Personal information you provide may be used for secondary 6Z 3 Cf <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. V2, <br /> II. Application Information—Please Print AU IInformation C.A-(10 0 r <br /> Property Owner's Name ( Parcel# 07 004 r gFY 17 j 7 <br /> Property Owner's railing Address Property Location/4) ./ *� Z T lo- <br /> 4 <br /> i4 13 6'//i-) ."e,s- 0 i- Govt.Lot l <br /> City,State Zip Code Phone Number y, 1 7 <br /> /a, Section <br /> .E=5/'/Q/ity, <br /> —I-- 5-03ll r r 42 7 (circle one i) <br /> EL Type of Building(check all that apply) Lot# T `3 S N; R / 7 E o`-� <br /> Lei or 2 Family Dwelling-Number of Bedrooms /0,; Ley k Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use ❑ City of ----- <br /> ❑State Owned-Describe Use CSM Number El Village of �t <br /> V I p ,27 Town of ,//�l 441/�J5 <br /> I.Type of Permit: (Check only one box on line A. Complete line B if applicable) v <br /> A' ❑New System Replacement System 0 Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> 13. i 0 Permit Renewal 0 Permit Revision 0 Change of Plumber 0 Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of P$WTS System/Component/Device: (Check all that apply) <br /> Non-Pressurized In-Ground 0 Pressurized In-Ground 0 At-Grade ❑ 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 IInformation: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> i �Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units b <br /> New Tanks Existing Tanks `ii '3'' <br /> d `6 , i,12 e <br /> n U 'vs y iv 0 0., <br /> e <br /> gptir Holding Tank 4,700ol / Gc//e.5 �� "74-- <br /> Dosing <br /> � <br /> Dosing Chamber C/W�''GG// 07e46-0 <br /> VIIII.Ikesponsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Si atureMP/MPRS Number Business Phone Number <br /> WADE RUFSHOLM 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 0 Disapproved Permit Fee Date Issued Issuing Agent Signature <br /> ❑ Owner Given Reason for Denial �7S i D•/3 •2—v <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Ck* 1544 I.315 <br /> IECEOVIE <br /> I <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 i/t . I hes in size <br /> 001122020 <br /> SBD-6398(R0313) <br /> Burnett County <br /> Land Services Department <br />