Laserfiche WebLink
County _ / i <br /> Safety and Buildings Division c40/'A)e-"T� <br /> 0 s . _ 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> , `\ P- Madison,WI 53707-7162 Z t4 <br /> Sanitary Penult 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 Addre_edifferent than mailing address) <br /> the Department of Safety and Professional Servies. Personal information you provide may be used for secondary t,b� <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stets. <br /> / ���0�� <br /> I. Application Information-Please Print Ail Information <br /> Property Owner's Name Parcel# O 7 Cis' 9 /6 7 .5— <br /> Property Owner1eMailing Address Property Location <br /> � ��`�3> / 9�'�S�S c h�5�; `-e �'c✓r4 y Govt.Lot <br /> City,State Zip Code Phone Number y, /,, Section 7 <br /> 657 4/ 70 a , <br /> �,,,f� , , ,-v c o?3e?S (circle one) <br /> T 3/ N; R /p Ewe <br /> II. ype of Building(check all that apply) Lot# <br /> r 2 Family Dwelling-Number of Bedrooms 5 7 Subdivision Name r <br /> Block# Q-55 G/, 5 /9/r)el 5 <br /> ❑Public/Commercial-Describe Use ❑Cityof <br /> ❑State Owned-Describe Use <br /> �— CSM Number ❑Village of <br /> Town of 7)7`e-c.„i0d...c) <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑New System / .R placement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> i ❑ Permit Renewal 0 Permit Revision ❑Change of Plumber List Previous Permit Number and Date Issued <br /> B. <br /> ❑Permit Transfer to New <br /> Before Expiration Owner <br /> j IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> ❑Non-Pressurized In-Ground ❑ Pressurized in-Ground ❑At-Grade A Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> Holding Tank ❑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(sit) Dispersal Area Proposed(sf) System Elevation <br /> �/.5-d / 47/S(7 yj--C �3.. / <br /> VI.Tank InTo I Capacity in Total #of Manufacturer <br /> Gallons Gallons Units p o 0 <br /> New Tanks Existing Tanks t g y E y a g <br /> ct U v- 73 rn w CD C. <br /> pticor,1,la;,,5Ta„k 5(9e 75 D /'- 70 .:7 40G� 7'6...e,e5 ma's'' <br /> Dosing Chamber a — 2,e) / X/ <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 h. ) / 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> I PO BOX 514,SIREN,WI 54872 <br /> VIII.County/Department Use Only <br /> Permit Fee Date Issued I i g A nt Sig u <br /> I epProved 1 0 Disapproved <br /> ❑Owner Given Reason for Denial $H a"5 i II I <br /> IX.Conditions of Approval/Reasons for Disapproval C V E -[1 <br /> Y ke4- al( <br /> q,.F� q56 fg.3c�s rhµ3f � or above 958 IGlcy <br /> JUN 2 8 2022 <br /> 4 4,.):300 Pi <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 IR x 11 ir;hec in cize <br /> Burnett County <br /> Land Services Department <br /> SBD-6398(R. i 1/1 l) <br />