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Safety and Buildings Division <br />County <br />V �'� 1400 E Washington Ave <br />Qfl, <br />Sanitary Permit Number (to be filled in by Co.) <br />3. P P -O. Box 7162 <br />R <br />Madison, WI 53707-7162 <br />Sanitary ]Permit Application <br />State Transaction Number <br />N� , <br />In accordance with SPS 38321(2), Wis. Adm. Code, submission of this form to the appropriate governmental unit <br />Note: Application forms for state-owned POWTS are submitted to <br />Project Address (if different than mailing address) <br />is required prior to obtaining a sanitary permit <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. 15.0 1 m), Stats. <br />Parcel # 0 '7- O V 7- —0/-7 <br />I. Application Information - Please Print All Information <br />Property ONyner's Name <br />G, L. ArL4 re -1 <br />o - ©00 - CV do <br />�vA)A <br />Property Owner's Mailing Address <br />Property L °canon BOG <br />Q <br />02 70 o 5- <br />Govt Lot <br />�C y, ya Section <br />City, State <br />Zip Code <br />Phone Number <br />TN R 17 (�ClEone <br />OOD <br />H. Type of Building (check all that apply) <br />Lot # <br />Subdivision Name <br />�Ll or 2 Family Dwelling -Number of Bedrooms <br />�- <br />Block # <br />❑ City of <br />r— <br />❑ Public/Commercial - Describe Use <br />-� <br />❑ State Owned -Describe Use <br />El village of <br />Town of tJG � <br />CSM Number <br />r- <br />III. Type of Permit: (Check only one box on line A. Complete line B if applicable) <br />A. <br />❑ New System <br />:Replacement System <br />❑ Treatment/Holding Tank Replacement Only <br />❑ 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 S stem/Com onent/Device: Check all that apply) <br />ONon-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/Treatment Area Information: <br />Design Flow (gpd) <br />Design Soil Application Rate(gpdsf) <br />Dispersal Area Required (st) <br />Dispersal Area Proposed (so <br />System Elevation <br />.3�0 <br />, 5 <br />60 0 <br />zo 0 <br />9� <br />VI. Tank Info <br />Capacity in <br />Total # of Manufacturer <br />o <br />Gallons <br />Gallons Units U <br />L <br />v <br />New Tanks <br />Existing Tanks <br />o Z <br />a U in h <br />n R <br />rn w <br />Septic or IduJding Ta k <br />75 0/ C <br />I <br />Dosing Chamber <br />VII. Responsibility Statement- I, 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/M <br />Business Phone Number <br />WADE RUFSHOLM <br />(/(/ G•D�- <br />227691 <br />715-349-7286 <br />Plumber's Address (Street, City, State, Zip Code) <br />PO BOX 514, SIREN, WI 54872 <br />VIII. Coun /De artment Use Only <br />Approved <br />❑ Disapproved <br />Permit Fee <br />Date Issued <br />Issuing Agent Signature <br />❑ Owner Given Reason for Denial <br />IX. ditions of Approval/Reasons for Disapproval , AqNJt15 <br />��0�� 7;, &Iedil t 51�4�e is Critlt 9S.gg-9�,� E � E � V E <br />D <br />n <br />1170) MAY 2 4 <br />1AVVKI 1U r1l to complete plans for the system and submit to the County only on paper not less than 8 LS x 11 itflies i ize <br />Its -2--olk a r BURNETT COUNTY <br />ZONING <br />