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County/' <br /> Safety and Buildings Division <br /> _ 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> SP Madison,WI 53707-7162 Sim _ 2C f <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 /> 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 /> u oses in accordance with the Privacy Law,s. 15.04 1 m,Stats. <br /> i. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# 07 06 /7 J 9 <br /> P-eper.y Owner's Mailing Address Property Location N C l 7'ax iD Z 350 <br /> Govt.Lot <br /> Ci y,State Zip Code PhonelJNumber �y, ��y,, Section <br /> J f rrm� ., , q f State►7,? '0 7 /`'7_u, y/ (circle one <br /> ' (r✓l 7 o iC. D7 7 ' T �N; R�_E o Wi) <br /> _... ype of Building(check all that apply) Lot# <br /> er 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block# <br /> i 1 Public/Commercial-Describe Use <br /> i ❑City of <br /> ' CSM Number ❑Village of <br /> E UI State Owned-Describe Use <br /> r-� P-_Town of <br /> ill.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> i A. ❑New System Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> i <br /> .. � � Permit Renewal ❑ Permit Revision ❑ Change of Plumber ElPermit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner 'V V <br /> N.Type of POWTS System/Component/Device: Check all that appi <br /> ; 'Von-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> i <br /> Bolding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dis ersalfrreatment Area Information: <br /> Design.Flow(gpd) 1 Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> -nk info Capacity in Total #of Manufacturer y <br /> Gallons Gallons Units U N r <br /> New Tanks Existing Tanks °J� awl c <br /> U in is C7 0. <br /> Septic or Ft— - k <br /> Dosing Chamber 7s-Q <br /> i 11.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 /> NYADE RUFSHOL V ,�Jr 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX 514,SIREN,Wl 54872 <br /> V;;II.County/Department Use Only <br /> Permit Fee Dat Issued Issuing Agent Signature <br /> Approved ! El Disapproved $ <br /> i i ❑Owner Given Reason for Denial `� !✓� <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> �p10-i 0_U Ca.vtf`f �t� E <br /> CIE WE <br /> n[DAttach to complete plans for the system and submit to the County only on paper not less than 8 112 xn��4s in Sus <br /> L <br /> UN 2 8 2024 <br /> S20-6398(R. i l/I l) Burnett County <br /> Land Services Department <br />