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„reaxAri"�Hr'+. County <br /> Safety and Buildings Divisionfit <br /> 't S 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> PP.O. Box 7162 r/ <br /> ' S Madison,WI 53707-7162 b 7 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(2),Weis.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 addres ) <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),Slats. <br /> I. Application Information-Please Print All Information <br /> Prop Owner's Name n ( Parcel#d 7 <br /> Property <br /> COwner's Mailing A,ddddressssD Property Location <br /> Govt.Lot <br /> City,State ode Phone Number y, , of <br /> /,, Section <br /> lizeipoc <br /> Y� (circle one) <br /> 11.Type of Building(check all that apply) Lot# T N; R E o ' <br /> �1 or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use ❑City of _ <br /> CSM Number ❑Village of !' <br /> 11State Owned-Describe Use �L <br /> �,_Townof <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑New System lacement System ❑Treatment/Holding Tank Replacement Only Other Modification to Existing System(explain) <br /> u <br /> B. -❑ Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> W.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 /> 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 /> 3ovI I I — <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units °o v <br /> New Tanks Existing Tanks <br /> Septic or Holding Tank Z>0-0 17 060 <br /> Dosing Chamber <br /> VII.Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plum Signature 227691 S Number Business Phone Number <br /> WADE RUFSHOLM Qom(./.� 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 <br /> VIII.County/-eartment Use Only: <br /> ( ❑ Permit Fee Date Issued Issuing Agent Signature <br /> Approved Disapproved <br /> ❑ Owner Given Reason for Denial <br /> >X.Conditions of ApprovalfReasons for Disapproval <br /> /rlN� o �2 a?S'or /Y7mst i�oA+ WeIG, PLeJt�i/aar aows To �e LCesC . <br /> HE EIVE -F))Attach to complete plans for the system and submit to the County only on paper not less than a 1/2111aiAUG <br /> 2 5 2015 <br /> BURNETT COUNTY <br /> ZONING <br />