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I 'y.F'i 1f1•;.... County / <br /> 1 "; Safety and Buildings Division G//",fJ PJ <br /> 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> P.O.Box7162 (a376qy <br /> Madison,WI 53707-7162 <br /> I <br /> Sanitary Permit Application StateTransactio <br /> in accordance with SPS 383.21(2),Wis.Adrr Code,submission of this form to the appropriate governmental unit Q W I S OS <br /> ®2.10 2.0(4 y 6 <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 #Z O 3 3a-3 <br /> purposes in accordance with the PrivacyLaw,s.15.0 1)m,Slats. O <br /> 1 1, Appfication Information—]Please Print All Information <br /> 1 Property Owner's N me Parcel# O 7 O ya 12 <br /> i l <br /> ,e 79 <br /> A)A)e ��'i c.kS 0�✓ Al 0 3 006 30o6 <br /> Pt operty Owner's Mailing Address Property Location /5 c/ <br /> 7 4 G� f <br /> Goy Lot <br /> Ss:a'e 5//_♦ /� LZ,i (C�o/yd'e Phone Number S� <br /> �' / (J / Jp7 l� 1/a,�(���a, Section )_ <br /> (Y �� Q7 cucleone <br /> Type of Building(thee all that apply) Lot# D v T N; R E o yN <br /> or 2 Family Dwelling-Number of Bedrooms ✓ Subdivision Name <br /> f Block# <br /> x vblic/Commerciai-Describe Use <br /> i ❑City of <br /> State Owned-Describe Use f CSM Number ❑ village of <br /> Town of <br /> i <br /> I-[.'l R.Type of]Permit: (Check only one box on line A. Complete line B if applicable) <br /> ? A. Ds New System replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> i <br /> I <br /> jT• Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.T e 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 /> j J Hoiding Tank Cl 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 /> � ysd �5 0 <br /> 7L Tea ink lnfo Capacity in Total #of Manufacturer <br /> Gallons Gallons Units L o a <br /> New Tanks Existing Tanks w o Zi <br /> i i rs.U in ti � w c7 a, <br /> Septic or H6Tring Tan D aDO �/D <br /> I �7 <br /> yi Dosing Chamber <br /> I Vll.Responsibility Statement-1,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 /> INADE RUFSHOLM 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 <br /> I <br /> �(ll.Conn /IlDe artment Use Only <br /> Permit Fee Date Issued g Siga e i?Approved El Disapproved $ <br /> 1 ❑Owner Given Reason for Denial <br /> i lam.Colndlitions of Approval/Reasons for Disapproval `� •#tl�5 <br /> -R <br /> E 4Z5"s 2111 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 ines in size <br /> SBD-6398(R031.3) Burnett County <br /> i Land Services Department <br />