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..,,,,•,.,--%,- County ,/ <br /> I NSafety and Buildings Division �1/' e_-#-_ <br /> 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> f, <br /> `,, 'r MadisonS .f ,WI 53707-7162 ,j-,.22_59 <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 Servies. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. ,75;/ `br J ':: <br /> I. Application Information-Please Print All Information ' <br /> Property Owner's Name Parcel# c s 7 C)/„7 V ) /$'c: / <br /> e <br /> D / <br /> 1� c A�b re GI;-/- 5 0_5— C O` 0,7/oea <br /> Property Owner's Mailing Address Property Location / <br /> li ,Z7'/Y 5-m€rl31ci LCL) Govt.Lot <br /> City,State Zip Code Phone Number <br /> /� /a, /<, Section , <br /> S 1 / 4,, / /79 rt) .5 //ei G//-'7 3C')7 G 3 75 (circle ons).„IL Type of Building(check all that apply) Lot# T yn N; R /..5— E o(�U <br /> Vi-or 2 Family Dwelling-Number of Bedrooms ' — Subdivision Name <br /> Block# — <br /> 0 Public/Commercial-Describe Use --- <br /> 0 City of <br /> ❑State Owned-Describe Use „...----- CSM Number 0 Village of -t- <br /> ,Town of '�! i75 411- <br /> IIL Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. 0 New System �Replacement System 0 Treatment/Holding Tank Replacement Only 0 Other Modification to Existinb System(explain) <br /> ) <br /> I <br /> B. 0 Permit Renewal 0 Permit Revision <br /> 0 Change of Plumber 0 Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> i <br /> IV.Type of POWTS 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) ❑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 /> ys6 , 7 y -ssr...�5 73,C <br /> e_.4....., <br /> VI.Tank Info , Capacity in Total #of Manufacturer �' <br /> :1 <br /> Gallons Gallons Units c o 7,1 0 <br /> -IPNew Tanks Existing Tanks y c y = Y 2 R <br /> g U in Gm rn Cz. C7 r�., <br /> I Septic or.licldiag-T-ank <br /> �00 Siu oo //op d� /1-Iorc. i e.SC,c` 'f-7A';€-5-e% '2-- 4-- <br /> Dosing Chamber <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 / �_�i_ 1 227691 715-349-7286 <br /> I Plumber's Address(Street,City,State,Zip Code) 4 �� <br /> PO BOX 514,SIREN,WI 54872 <br /> VIII.County/Department Use Only / <br /> Approved 0 Disapproved Permit Fee Date Issued Is uing Age t Sign. <br /> 375 5la/?a � • 7�� <br /> ❑ Owner Given Reason for Denial _ <br /> IX.Conditions of A proval/R anon for Disapproval /' ' `1 1-1. 3 1 3-25 <br /> JECIEINE, Th <br /> , APR 2 7 2022 r JI <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x/1 nc in size <br /> Burnett County <br /> SBD-6398(R. 11/11) Land SerVloeS DeptAttthsttt <br />