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0, County <br /> y Safety and Buildings Division +a>-At e <br /> _ p _ 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> P Madison,WI 53707-7162 SA�_ m <br /> State Transaction Number <br /> Sanitary Permit Application <br /> 3 In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit <br /> i 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 <br /> purposes in accordance with the Privacy Law,s. 15.04 1 m,Slats. JJ <br /> I. Application Information—Please Print All Information Xiv/t� <br /> Property Owner's Name Parcel#cP '7 p/5/ a 3 8'1 so 1 <br /> 7 s 0s o 0 <br /> Property Own is Mailing Address <br /> Property Location O --- •�-G1X`p�31(p <br /> ,55J�-�� �37 /� (J� Govt.Lot t z <br /> i City,State Zip Code Phone Number y4 57 <br /> f `'� /<, Section <br /> 5/yJN -��l ° 6�,2 s$- .z 7 y cucle one <br /> II.Type of Building(check all that apply) Lot# T�_N; R /� E o� <br /> Y-or 2 Family Dwelling—Number of Bedrooms Subdivision Name <br /> Block# <br /> ❑Public/Commercial—Describe Use City of <br /> ❑ �— <br /> i ❑ CSM Number Village of <br /> Owned—Describe Use 7 <br /> t /a 9/0 3 KTown of Z—X 4a Q _ <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ?Alew System ❑ Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. I ❑ 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 System/Component/Device: Check all that apply) <br /> ❑Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade OLMound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> El 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 /> y y-5-0 5�.5 o S.9 <br /> VT.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o o <br /> 5 V V U y n <br /> i New Tanks Existing Tanks o <br /> t U <br /> Septic or Hold n /O D o D00 r <br /> Dosing Chamber Dd <br /> VIL 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 ��/J _ / 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 <br /> VIII.County/ e artment Use Only <br /> Approved ! El Disapproved Permit _ Date Issued Issuing Agent G� Signature <br /> ❑ Owner Given Reason for Denial <br /> IX.Conditions of Approval/Reasons for Disapproval 4- <br /> e-- av s��dj-S rRnl m,,Ay fi Y ?n7h <br /> C� 0VE <br /> Rllow a u M Ugy O d S-ko .,y t f� <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x I I h i size <br /> Burnett County <br /> Land Services Department <br /> SBD-6398(R. 11/11) <br />