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rrlu`; County <br /> Safety and Buildings Division & <br /> , 17"J.. <br /> P 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> 1 p Hi P.O.Box 7162 SAN -�.( a 1 <br /> I S Madison,WI 53707-7162 <br /> . .-- -- 6.3 ) y .5-1. <br /> Number <br /> Transaction ransacon <br /> Sanitary Permit Application State /. <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 <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name / Parcel# Q 7 6 3 Y 27/ 30 <br /> —ro y Zur'/fcvco <br /> 5k/ s 9' oeo/yt7 <br /> cra <br /> Property Owt>wndr's Mailing Address Property Location pc i _di2-y/7,/, <br /> i ), '7 7 3 C:fry /°G// 2 Govt.Lot <br /> City,State Zip Code Phone Number C 1/4,..5C3 /,, Section 3d <br /> N �t i/9. /�- 5-W*) lis 79/ & 2 (circle one <br /> l'� T .�7 N; Ra E. <br /> i .Type of Building(c`b'eek all that apply) Lot# <br /> Xi or 2 Family Dwelling-Number of Bedrooms 3 -V Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use ^-_---' <br /> ❑City of <br /> CSM Number 0 Village of <br /> ❑State Owned-Describe Usc ,, !� <br /> V 3 P 5 T.Town of ` f 4c - Z---/C l <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑New System )1.Replacement System 0 Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> 1g. 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 POWTS System/Component/Device: (Check all that apply) <br /> 0 Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> Hoiding Tank 0 Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(st) Dispersal Area Proposed(sf) System Elevation <br /> — <br /> VII.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units ,a t "g <br /> New Tanks Existing Tanks o J 2 '�a m <br /> n. O cn . s 4. <br /> 0 P, <br /> 1 <br /> 6epttC'or I-Iolding Tank ,,2�,0 0 75-2> ,,7 -17 ,Z /v r/e sUp j.. <br /> 1 Dosing Chamber s <br /> VII.Responsibility Statement- I,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 /> WADE RUFSHOLM /f / �///��9�� _�� 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) (/t G���- X20" <br /> PO BOX 514,SIREN,WI 54872 <br /> VIIIII.County/Department Use Only <br /> Approved 0 Disapproved Permit Fee Date Issued Issuing Ag)ent S1gn tore <br /> 0 Owner Given Reason for Denial S-37-57 / <br /> `3 '14 •'V lamge <br /> IX.Conditions of Approval/Reasons for!I isapproval <br /> -U -4', I5571 1375 <br /> 4.;4Y *- C ADZ. r'ectrrle� C © E OMC Th <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 113, <br /> in size <br /> NIAX 1 5 10`1 <br /> SBD-6398(R0313) <br /> Burnett County <br /> Land Services Department <br />