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County Safety and Buildings Division <br /> 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> P.O.Box 7162 <br /> w; Madison,WI 53707-7162 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of tltis form to the appropriate governmental unit <br /> 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 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 /> II. Application Information-Please Paint All Information <br /> Property Owner's Name Parcel# <br /> 07 ® <br /> s/5- oy3 <br /> Property Ow er's Mailing Add re s Property Location <br /> (j Sa y �7, fG�GG�� Govt.Lot <br /> City,State Zip Code Phone Number V4, 14, Section <br /> S it, <br /> eJ y- 15-14197.2 /�,c' le one <br /> IIII.Type off Building(check all that apply) Lot# T�N' R-`-'_E o <br /> Eli or 2 Family Dwelling-Number of Bedrooms _3 L! Subdivision Name r <br /> Block# ���m <br /> ElPublic/Commercial-Describe Use ❑ City of <br /> CSM Number El Village of �— <br /> ❑State Owned-Describe Use <br /> 5r Town of <br /> in.Type of Permit: (Check only one box on lane A. (Complete Pane B if applicable) <br /> A. P Y �A g P Y g Y (explain) <br /> ❑New System Replacement System Tra�ltst/Holdin Tank Replacement Only ❑ Other Modification to Existing System <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POUF TS System/Component/Device: (Check all that a 1 <br /> ❑Non-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) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 3 c)o <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units a o <br /> New Tanks Existing Tanks y c L <br /> a U in 60 4% <br /> Sehtieor Holding Tank �7c9e)e) <br /> Dosing Chamber <br /> VIIII.responsibility Statement- ➢,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 /> WADE RUFSHOLM o' I L /! 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 <br /> VVIIIIII.(Count /lDe artment Use Only <br /> Permit Fee Date Issued Issuing Agent Signature <br /> Wlkpproved ElDisapproved $ q t, <br /> El Owner Given Reason for Denial 2 a / , r <br /> III.OApfkOVE <br /> proval/l8easons for Disapproval <br /> in I <br /> MAY 2 0 2019 <br /> (attach to complete plans for the s n and aper not less than S to 1 i es in size <br /> S$I�-6398(R0313) /` �4���GC Burnett County <br /> Land Services Department <br /> �/y <br />