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rr EY'j,. County <br /> Safety and Buildings Division <br /> s � 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> ;s P.O. Box 7162 �C3 <br /> PS f^� Madison,WI 53707-7162 <br /> Sanitary Permit Application State Transaction Num er <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit C D✓ro7 y PdC+r+f/ <br /> is required prior to obtaining a sanitary permit. Note:Application forms for state-owned POWTS are submitted to Project Address(if different than mailinaddress) <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. r <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name / Parcel 4 o '7 o3 4/ R 37 le�2/ <br /> n)e- Lc-P A o5-e)0o/ 000 <br /> Property Owner's Mailing Address Property Location �r <br /> Q L4 2 r /tom Govt.Lot r <br /> Cl.ty,state v Zip Code Phone Number y4, %4, Section 2� <br /> Z A) $i/3 (circle one <br /> 77 T <br /> H.Type of Building(check all that apply) � # _Z.7 N; R 1 E <br /> Yi-or 2 Family Dwelling-Number of Bedrooms d -&// Subdivision Name <br /> ii ck N ! <br /> ❑Public/Commercial-Describe Use <br /> El of �-- <br /> r� <br /> ❑State Owned-Describe Use CSM Number 11 Village of <br /> XTownofY �- <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' ❑New System �O.Replacemcnt System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B• El Permit Renewal El Permit Revision El Change of Plumber ❑Permit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.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 /> ,gaolding Tank ❑Other Dispersal Component(explain)___ ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gost) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> VI.Tank Info Capacity in Total 8 of Manufacturer <br /> Gallons Gallons Units a <br /> New Tanks Existing Tanks roo <br /> -Upke <br /> -or Holding Tankr- ��,v ��-� <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) I Plumber's Signature MPIMPRS Number Business Phone Number <br /> WADE RUFSHOLM / 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) t� <br /> PO BOX 514,SIREN,WI 54872 <br /> VIIL Coun /De artment Use Only <br /> Permit Fee Date Issued Issuing Agent Signator <br /> Approved ❑ Disapproved $ �� tl O <br /> ❑Owner Given Reason for Denial <br /> y-18�11 <br /> iL <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> ,r j i Alk T Neel-BICC Sefdagfks . <br /> p ECE91SE <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 r ches P size� O 2016 <br /> R <br /> BURNETT COUNTY <br /> ZONING <br />