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bi irriir:;; ,a <br />County <br />Safety and Buildings Division����,) <br />1400 E Washington Ave <br />Sanitary Permit Number (to be filled in by Co.) <br />P.O. Box 7162 <br />_ <br />Madison, WI 53707-7162 <br />s -I y <br />l' l `, <br />Sanitary Permit Application <br />State Transaction Number <br />3 / s y13 <br />In accordance with SPS 383.21(2), Wis. Adm. Code, submission of tlus form to the appropriate governmental unit <br />9 <br />Project Address (if different than mailing address) <br />is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are submitted to <br />the Department of Safety and Professional Services. Personal information you provide may be used for secondary <br />13 -IV <br />oses in accordance with the Privacy Law, s. 15.04 1 m , Stats. <br />/� <br />D (� <br />I. Application Information— Please Print All Information <br />Property Ojnler's Name / <br />R i c.., � A- i -d !� C o b <br />Parcel # 0a2 <br />©S- a ao? - 00 <br />Property Owner's Mailing Address <br />Property Location G <br />Ai Ll 'e <br />Govt. Lot ;2 - <br />y., /6, Section 7 <br />City, State <br />Zip Code <br />Phone Number <br />r <br />,q �.�/ <br />�'J �' <br />�circle one <br />TN; R1�Eo W <br />II. Type of Bu ding (check all that apply) <br />Lot # <br />Subdivision Name <br />or 2 Family Dwelling — Number of Bedrooms <br />Block # <br />❑ Public/Commercial — Describe Use <br />❑ City of <br />❑ State Owned— Describe Use <br />❑ Village of <br />CSM Number <br />Town of <br />III. Type of Permit: (Check only one box on line A. Complete line B if applicable) <br />A' <br />❑ New System <br />y <br />a lacement System <br />p y <br />❑ Treatment/Holding Tank Replacement Only <br />El Other Modification to Existing System (explain) <br />B. <br />❑ Permit Renewal <br />❑ Permit Revision <br />❑ Change of Plumber <br />❑ Permit Transfer to New <br />List Previous Permit Number and Date Issued <br />Before Expiration <br />Owner <br />IV. Type of POWTS System/Component/Device: Check all that apply) <br />❑ Non -Pressurized In -Ground ❑ Pressurized In -Ground ❑ At -Grade ;9 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) <br />Design Soil Application Rate(gpdsf) <br />Dispersal Area Required (sf) <br />Dispersal Area Proposed (sf) System <br />Elevation <br />VI. Tank Info <br />Capacity in <br />Total <br /># of <br />Manufacturer <br />Gallons <br />Gallons <br />Unitsf, <br />o <br />c 0 <br />n`. . <br />New Tanks <br />Existing Tanks <br />. <br />0 . <br />U in <br />rn <br />Septic or N5ldht�nk <br />OQ `� <br />O <br />f <br />Dosing Chamber <br />O <br />Voo <br />H-1 <br />t -,V7 "�-- <br />F-4-1 <br />VII. Responsibility Statement- 1, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. <br />Plumber's Name (Print) <br />Plumber's Signature <br />MP/MPRS Number <br />Business Phone Number <br />WADE RUFSHOLM <br />227691 <br />715-349-7286 <br />Plumber's Address (Street, City, State, Zip Code) <br />PO BOX 514, SIREN, WI 54872 <br />VIII. Coon /De artment Use Only <br />Approved <br />❑Disapproved <br />Permit Fee D <br />$ 0� <br />Issued <br />Issuing Agent Signa e <br />❑Owner Given Reason for Denial <br />v S` <br />QD'ate <br />o I V <br />IX. Conditions of Approval/Reasons for Disapproval <br />APPROVEDI <br />Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 1 1 in yes in size <br />i <br />SBD -6398 (80313) <br />AUG 2 0 2018 <br />iJ <br />BURNETT COUNTY <br />7nNING <br />C� <br />