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County <br /> ,_ Safety and Buildings Division I3gI &e_ <br /> p _ 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> S p Madison,WI 53707-7162 .gyp �y/_/ 3 <br /> —e2 <br /> e-ST.2it-110 158'5 78' <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 purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. 5qQ //O/ P Ike- L•naKe- <br /> I. Application Information-Please Print All Information • <br /> { Property Owner's Name Parcel# 0 7 0/8 .Z 39/6.?S-S <br /> 6"ric_ Ltidy 0., ©03 o/raoo <br /> Property Owner's Mailing Address Property Location ,OG -7 <br /> W5710.X-M 11% Il <br /> Ph K&o oci Dr, Govt.Lot /t3 <br /> City,State Zip Code Phone Number 1,, /, Section p?� <br /> 5i4/I c I A;re c).7- Sy7o3 7is' 6 '/ /e7o T 07 <br /> N; R !, (circle or <br /> I.Type of Building(check all that apply) Lot# <br /> /1'sk.or2 Family Dwelling-Number of Bedrooms oC+�f Y Subdivision Name <br /> ,_ Block# <br /> CI Public/Commercial-Describe Use ❑ City of <br /> .----- <br /> State Owned-Describe Use CSM Number ❑ Village of <br /> VI / /C own of "ijee.vo 0 <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. I ❑New System ' Replacement System 0 Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> I <br /> B. ❑ Permit Renewal i ❑ Permit Revision ❑ 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 /> lon-Pressurized In-Ground ❑Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil 0 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 /> 300 ; , eao Sao 9‘, c <br /> VI.Tank Info Capacity in Total #of Manufacturer y <br /> Gallons Gallons Units s, 0, o 0 <br /> ! New Tanks Existing Tanks v o 0 8 `H <br /> i <br /> U in ,, rn iy e C, <br /> Septic or tiYikli,.,,lank 1 Q 5/v S fo <br /> j Ge)1e5er X <br /> Dosing Chamber 5.b0 S� <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 ' r / 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX 514.SIREN,WI 54872 <br /> VIII.County/Department Use Only <br /> Permit Fee Date Issued Issuing Agent Signature <br /> Approved ❑ Disapproved $y25'° b Iiq/zv g ,� <br /> 0 Owner Given Reason for Denial [.ve <br /> IX.Conditions of Approval/Reasons for Disapproval C'kit 1 "), :3-2 $'-t 1 <br /> f�lhw a� cow► i �d S4��e. '�r�►nu fs <br /> I A I N 13 2C24 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 iiIIL3emitsize <br /> Burnett County <br /> Land Services Department <br /> S13D-6398(R. 11/11) <br />