Laserfiche WebLink
Safety and Buildings Division 0� ; z <br /> ' ,; g '1 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> `�Sp i�I Madison,WI 53707-7162 Sf-93 Li <br /> ip5092.3 <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 C/ <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. ,7q /35 0 -jt{Jeti Sp�J <br /> I. Application Information-Please Print All Information ' <br /> Property Owner's Name /� Parcel#p 7 cri0 6 oZ 3S/7//oZ <br /> Wil/jiM �v ,_C�Ae.r © ace) 0//trot) ,21).)It( <br /> Property Owner's Mailing Address / Property Location QL/ <br /> SY J/ S /¢AJ9 e T9 /QO' Govt.Lot <br /> el City,State Zip Code Phone Number /IJ[,1 j y, l()(i y, Section 1 l <br /> Gf/ Sle r vl/•1- 5 Yg'3 //Y /33 e9 -7y T ✓ff N; R /t/7(circleEW on <br /> II.Type of Building(check all that apply) Lot# <br /> 0yor 2 Family Dwelling-Number of Bedrooms �.— Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use �/ CSM Number ❑ Village of r--" <br /> 7Ntown of /"1 e—/5 <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. P'tdew System 0 Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber 0 Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> X.Non-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 /> 3 a 6 , 7 y29 yea T7 <br /> VI.Tank Info Capacity in Total #of Manufacturer Y <br /> Gallons Gallons Units .c� °' o j : N t) <br /> New Tanks Existing Tanks eu o �; g u , <br /> ( <br /> ct U in y v, rs. CD a. <br /> Septic or Holding Tr,k 73-7 2 o I 4) fe,e5 e /---- <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 / 227691 715-349-7286 <br /> leAd/e---147-"1"- ---- <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 <br /> VIII.County/Department Use Only <br /> IZI <br /> Approved ❑ Disapproved Pe t Fee Date Issued Issui g gentot.+ a <br /> El Owner Given Reason for Denial <br /> '�S� 5/8f23 - / <br /> IX.Conditions of Approval/R asons for Disapproval (d(-4- ii p3 i 1.L4 <br /> i,rnee+ 411 Se- �r.S -t SI ; e 4s I j\ EC G II V <br /> J <br /> t <br /> !iny ' MHr Q 023 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 me in size 0 s+ 2 / <br /> l_; _J <br /> Burnett County <br /> SBD-6398(R. 11/11) Land Services Department <br />