Laserfiche WebLink
County <br /> Safety and Buildings Division <br /> 1400 E Washington Ave Sanitary Pennit Number(to be filled ipp c11�C���o.) <br /> P.O.Box7162 �RN�1 (ouO bOH <br /> Madison,WI 53707-7162 <br /> 41 <br /> Sanitanj Perm.t Application <br /> State Transaction Number <br /> n accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit <br /> j 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 �1` 0'!> <br /> oses in accordance with the Privacy Law,s.15.04(1)m,Stats. <br /> 1. Appfication Information-Please Print All Information <br /> Property Owner's Name � ! Parcel# 0 7 ev <br /> - r e a� <br /> p0o <br /> Property Owner's Mailing Address �j / Property Location <br /> ,� o/LJ.t}u�` ' /G Govt.Lot <br /> City,sta're Zip Code Phone Number y,, %<, Section 3,� <br /> ,.- _ ��_ <br /> ]t_�. ��e of Perri➢e7ing(check all that apply) Lot# T N; R E o ! <br /> 2.Family Dwelling-Number of Bedrooms r-;z Subdivision Name <br /> Block# Q'/'UI(JC, L l[ Ife/i <br /> 1'aNic/Corma-nercial-Describe Use f <br /> ❑City of <br /> .�S ate Owned ed-Describe Usef CSM Number ❑Village of <br /> -� Town of <br /> i <br /> j 1LA.Type pe of Permit: (Check only one box on line A. Complete line D$if applicable) <br /> A. <br /> j New System Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> i <br /> I Pr•A` ❑ Permit Renewal ❑ 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 a l <br /> Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade .Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> Si Hoiding Tank ❑Other Dispersal Component(explain) El Pretreatment Device(explain) <br /> n.IDis ersal/'1'reatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 3o v Y3 076�, 7 9r <br /> ,nuk flrtfo Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o y <br /> Ncw Tanks Existing Tanks <br /> wU in n wc7 a <br /> Septic or voiding Tank 7S <br /> i Dosing Chamber <br /> 1,/1ii.Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name Print Signature MP/MPRS Number Business Phone Number <br /> { ) Plumber's Si tore <br /> WADE RUFSHOLM / 227691 715-349-7286 <br /> �! <br /> ?lira 3ber's Address(Street City,State,Zip Code) <br /> PO BOX 314,SIREN,W1 54872 <br /> i VU1?.Coeanty(9➢e artment Use Only <br /> i `i Approved 9 ❑Disapproved Permit Fee as Date Issued Age Signature <br /> �.1 i Owner Given Reason for Denial p' <br /> conditions of Approval/Reasons for(Disapproval <br /> i <br /> At2�ch to complete plans for the system and submit to the County only on paper not less than 8 Ua x Il inch si <br /> SBD-6398(1'R0313) <br /> Burnett County <br /> Land Services Dep4rIMent <br />