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County <br /> Safety and Buildings Division <br /> As 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> P Madison,WI 53707-7162 <br /> , s <br /> c 46`fS641 <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 3s--7 <br /> -purposes in accordance with the PrivacyLaw,s. 15.04 1 m,Stats. <br /> I. Application Information—Please Print All Information '5, /-J t,V/t /Osu/14 <br /> Property Owner's Name // Parcel# O7 ar/2, <br /> 140- Se lb -15' 65' oo! o;zroov <br /> Property Owner's Mailing Address J Property Location pL/ 1,0 <br /> 7 S o d e of Dr, Govt.Lot l <br /> City,State _` ,I Zip Code Phone Number y4, %4, Section 3 <br /> E A) N, 5:<42 3 rcD N; R E le o W <br /> II. pe of Building(check all that apply) Lot# T 1 <br /> �or 2 Family Dwelling—Number of Bedrooms Subdivision Name <br /> Block# --' <br /> ElPublic/Commercial—Describe Use ✓ �-- <br /> ❑ City of <br /> ❑State Owned—Describe Use CSM Number ❑ Village of <br /> // /.27 own of _kl—,40<5 O <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑New System Ae lacement System <br /> y p y ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS S stem/Corn onent/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/Treat ent Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> So 17 G y3 qS, 7 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units n a o <br /> New Tanks Existing Tanks a i a <br /> U in w C7 CU <br /> Septic or HeMing-Tank <br /> Dosing Chamber O� O� <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 Signatur, MP/MPRS Number Business Phone Number <br /> WADE RUFSHOLM 1 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) or <br /> PO BOX 514,SIREN,WI 54872 <br /> VIII.Coun /De artment Use Only <br /> Permit Fee DateAb <br /> Zgent Si ature <br /> (, Approved ❑ Disapproved $ Oip Owner Given Reason for Denial <br /> IX.Conditions of Approv I/Rea ons for Disapproval <br /> ►�►�ee-�- cLu se k s+� C� L 0 M <br /> lols Ja i e comber 4 ►rt cn-or`W 1�� Se4b acis c4� �- <br /> ,�►�� 31 ini <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 fMd size <br /> Burnett County <br /> SBD-6398(R. 11/11) Lan <br /> d Services Department- - - <br />