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b as e� Cal* <br /> Safety and Buildings Division <br /> K <br /> 9t Sanitary Permit Number(to be filled in by Co.) <br /> 1400 E Washington Ave <br /> P P.O. Box 7162257 l� <br /> Madison,WI 53707-7162 <br /> •t- j. <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 38321(2),Wis.Adm.Code,submission ofthis form to the appropriate governmental unit <br /> is required prior to obtaining a sanitary permit Note:Application forms for state-named POWTS are submitted to Project Address(if different than mailing address) <br /> the Department of Safety and Professional Services. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. <br /> L Application Information—Please Print All Information <br /> Property Owner's Name Parcel# O 7 O C) 1/O a <br /> W 1 O 03 0 d-6 O <br /> Property Owner's Mailing Address Property Location <br /> u x e A) Govt Lot <br /> City,State z Zip Code Phone Number S SeI4,sL—501, Section <br /> e-1 s cr W J� Sy 51q 3 (circle one <br /> H.Type of Building(check all that apply) Lot# T_ N; R�_E oe <br /> �or 2 Family Dwelling—Number of Bedrooms / Subdivision Name <br /> Block# <br /> ❑Public/Commercial—Describe Use ❑ City of <br /> ❑Stats Owned—Describe Use CSM Number / ❑Village of 1 /�— <br /> V � a S J IXTbwn of t 2/7 ti C..t <br /> IIL Type of Permit: (Check only one boa on line A. Complete line B if applicable) <br /> A. ❑New System ❑R Replacement <br /> eP System ATreatrnent/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. List Previous Permit Number and Date Issued <br /> ❑ Permit Renewal ❑Permit Revision 11 Change of Plumber 11 Permit Transfer to New <br /> Before Expiration Owner al a <br /> IV.Type of POWTS System/Component/Device: Check all that a 1 <br /> �rvon-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑Mound 2!24 in.of suitable soil ❑Monmd<24 in.of suitabl soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dts ersaVrreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 3�D <br /> V1.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o 2 <br /> New Tanks Dusting Tanks o u y w <br /> aU fn q h wO a <br /> Septic or H@Wiffgr&k lea O •— DOO l.�/`Ge/e5 c C. <br /> Dosing Chamber <br /> VII.Responsibility Statement-L the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/WRS NumberBusiness Phone Number <br /> WADE RUFSHOLM l 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 <br /> VM County/Department Use Only <br /> Approved ❑Disapproved <br /> Permit Fee Q Date Issued Issuing Agent igm <br /> ` <br /> ❑Owner Given Reason for Denial 1 .3 3 7J D^ <br /> IIr.cona:cre na oiAplrro�al/Rooaona roc DiaalrProvd <br /> ECE9VE <br /> Attach to complete plans for the system and submit to the County only on paper not less than 812 x I ch q <br /> ins U <br /> 8 2016 <br /> -- -- - BURNETT COUNTY <br /> ZONING <br />