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I County <br /> _- Safety and Buildings Division 44 j'/il le, <br /> _ 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> P Madison,WI 53707-7162 JH N-oZL-71 <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 /> f 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 /> i the Department of Safety and Professional Servies. Personal information you provide may be used for secondary a g/07 3 <br /> purposes in accordance with the Privacy Law,s. 15.04 1 m,Slats. p t <br /> I. Application Information—Please Print All Information <br /> Property Owner's Name Parcel#a 7 6.20 <br /> Property Owner's Mailing Address Property Location -Tay- tD 3 3LP St <br /> q9 a5' 38y ' T!' I Govt.Lot <br /> City,State 2 ,�+� Zip Code Phone Number <br /> p �( y,, /<, Section ?a <br /> O i r✓r/T/"� /� 7 J 5% d 6 1 _`J O 7 4 D lJ (circle o <br /> II.'Type of Building(check all that apply) Lot# T N; R E o <br /> or 2 Family Dwelling—Number of Bedrooms 3 Subdivision Name <br /> Block# <br /> ❑Public/Commercial—Describe Use El city of <br /> CSM Number d4 4/93 ❑ Village of <br /> ID State Owned—Describe Use Town of ©TF f�y <br /> 1,+o <br /> 111.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. New System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> I <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> i € Before Expiration Owner <br /> .V.Type of POWTS System/Component/Device: Check all that apply) <br /> Nor,-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 /> c'7 i . 7 5? <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units 2 o b <br /> RI U U <br /> 3 New Tanks Existing Tanks o Y <br /> ( U to y rn w C7 G, <br /> l <br /> Septic or soil. Tank O L� D �� o r e S <br /> Dosing Chamber C/ <br /> I 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 / A 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 /> i Approved ❑ Disapproved $���e� �a i Iss��bo <br /> ed Issuin Agent Signature <br /> Owner Given Reason for Denial , <br /> ;tX.Conditions of Approval/Reasons for Disapproval <br /> Mid au SG�bdjS K ��1(� <br /> 01� d S rq GU ru�l�-J no <br /> V l.� <br /> � <br /> ., <br /> T Attach to complete tans for the system and submit to the County only on paper not less than 8 1!2 x 11 h size', g a, g 3 <br /> P P Y .�`��.=3� I .1 <br /> jig <br /> SBD-6398(R. I i/l I) U Burnett County <br /> Land Services Department <br />