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County/ <br /> Safety and Buildings Division VSe4 f%U�� <br /> { 201 W.Washington Ave., P.O. Box 7162 Sanitary ( yCo.) <br /> � _ g Sani Permit Number to be filled in b Co. <br /> `\ Madison,WI 53707-7162 5 ,2.2 i <br /> 7 <br /> State Transaction Number <br /> Sanitary Permit Application <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 97/Z <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. Q <br /> I. Application Information-Please Print All Information Ph'rd ef/0 ie) <br /> Property Owner's Name Parcel# 0 7 p,?o Z yO /6 oz. <br /> 3cE'_ (viderA /.5 4666 o gaov <br /> Property Owner's Mailing Address Property Location .q .1'Zm <br /> ✓ 9 5-/ ii k `.. L-.fi-ke_ X)ez1 Govt.Lot <br /> City,State ' 'S Zip Code Phone Number yo, %, Section �j <br /> td�L c/�i /4--F 5 /g73 6j.J� oe 0'7 u (circle on <br /> T !� N; R /6 E o W <br /> II.Type of Building(check all that apply) / Lot# <br /> flY\I or 2 Family Dwelling-Number of Bedrooms b / y Subdivision Name ' <br /> 1� Block# (--(5iI�i12 a/�F.S <br /> 0 Public/Commercial-Describe Use l ❑ City of <br /> �_.-i CSM Number Village of <br /> 0 State Owned-Describe Use ❑ <br /> Town of C,4 K I ,z i j <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑New System Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> f � <br /> B. 0 Permit Renewal 1 ❑ Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration i Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> 4Non-Pressurized in-Ground ❑Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> Holding Tank ❑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 /> 7.6 0 / 7 /h9C /'3c,e, „,-/ <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o 0 Q <br /> New Tanks Existing Tanks g o . ,c cn w.�~o R <br /> U in ct 3 0., <br /> Septic ortoldinefank a� ,R65) Mos ru;e e- <br /> sDosing Chamber { <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility f installation f the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumb is Ignature MP/MPRS Number Business Phone Number <br /> WADE RUFSHOLM �� 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 <br /> VI I.County/Department Use Only <br /> Approved ; ❑ Disapproved Petumit�Fee�,O Date Issued Issuing A nt Signat <br /> ❑ Owner Given Reason for Denial $ l v J I 1��/aa <br /> IL Conditions of Approval/Reaso s for Disapproval 4e1 �'�o2j <br /> (1� k(( 5e + S-�t / ft�.eHte4� D KC IE 0 V <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 I/2 1 dies in'size <br /> Burnett County <br /> SBD-6398(R. 1 I/1 1) Land Services Department <br />