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County. <br /> Safety and Buildings Division -F'--- <br /> < . 201 W.Washington Ave., P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> `ti Madison,WI 53707-7162 fl/0 -2.2 _ I <br /> *,,- C r-.22 -$ 2.. <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 kW a�0/.`vZ� "0 <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. `7 �` <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# _01 3(i _/6) <br /> 57(! i=hD ' 0/Pm�,/ . is-4-7 -- O35OGY) <br /> Property Owner's Mailing Address Property Location <br /> PO teal 58Zeoi <br /> Govt.Lot <br /> City,State Zip Code Phone Number ya <br /> /, Section <br /> C ��� � G/� ���� ircl� (i � � N; �l� E or e J1 <br /> II.Type of Building(check all that apply) Lot# <br /> I or 2 Family Dwelling-Number of Bedrooms /2/Subdivision� Name3 <br /> Block# SuG0%' /E> h -i f.5 Ai/1 <br /> 0 Public/Commercial-Describe Use <br /> ❑ City of <br /> 0 State Owned-Describe Use CSM Number 0 Village of <br /> --____ _ X Town of /f'_(,7Df <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' 0 New System Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. i 0 Permit Renewal ❑ Permit Revision 0 Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> 1 IV,Type of POWTS System/Component/Device: (Check all that apply) <br /> ylNon-Pressurized In-Ground ❑ Pressurized In-Ground ❑ 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(s1) Dispersal Area Proposed(sf) System Elevation <br /> 450 17 Lo643 ( 5O `)-:lv <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units an 2 o'd <br /> { New Tanks Existing Tanks `� o 0 g Ti� .a 2 2 <br /> rE v ,, w 5 Ta �r�./ <br /> Septic or IIuldirw ak 1//1/ / t) / ( X <br /> Dosing Chamber L (��f� �(—ICJ ��.��5f <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumbs 's Si nature MP/MPRS Number Business Phone Number <br /> WADE RUFSHOLM / J 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) (� <br /> 1 PO BOX 514,SIREN,WI 54872 <br /> I <br /> VIII.County/Department Use Only <br /> )(Approved I 0 Disapproved Permit Fee ../) Date Issued I suing ent Si <br /> 0 Owner Given Reason for Denial $ 2S-� ( l317d �'� <br /> IX.Conditions of Approval/Reasons f r Disapproval !'J J `lll 4 ft t1,{ 'nj 1 5 <br /> Mel' all 54 E ./ <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x I in in size <br /> Burnett County <br /> SBD-6398(R. I I/11) Land Services Department <br />