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r a:,, County <br /> Safetyand Buildings Division /� <br /> g C- <br /> 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> ` P.O.Box 7162 —1g—119 p <br /> , > Madison,WI 53707-7162 (VC�,J, I' O <br /> C <br /> ST—Ig <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 &14153 <br /> is required prior to obtaining a sanitary permit. Note:Application forms for state-owned POWTS are subnutted 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 /> m oses in accordance with the Privacy Law,s.15.04 1 m,Slats. V LJ/t <br /> L Application Information-Please Print AD Information <br /> Property Owner's Name Parcel# O 7 0 410 <br /> �A) C�f 6)0 e91 ooa 0)1� <br /> Property Owner's Mailing Address Property Location /V cL-1 <br /> G ve-r N4^ / Govt.Lot <br /> City,State Zip Code Phone Number 1V /<,IV a) <br /> /., Section <br /> �zq O_�S/e-p ZJ r -5 -(circle one) <br /> T N; R f-5 E or NP <br /> IIII.Type of Building(check all that apply) Lot# <br /> 1 or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use ❑City of --�� <br /> ❑State Owned-Describe Use <br /> CSM Number ❑Village of <br /> XTownof <br /> HR.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> ❑New System �4 Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal El Permit Revision ❑ Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POW'II'S System/Component/Device: Check all that a 1 <br /> 'o-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(so Dispersal Area Proposed(sf) System Elevation <br /> 5 Z, <br /> VI.Bank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o <br /> New Tanks Existing Tanks W c 0 R Y R <br /> U <br /> o <br /> ,) a v4) " v w C7 a <br /> Septic or�c /©Q�y 2,5 c--s C eJ <br /> Dosing Chamber / C/ <br /> VIIII.Responsibility Statement- 1,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 TBusiness Phone Number <br /> WADE RUFSHOLM ) 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) 1 <br /> PO BOX 514,SIREN,WI 54872 <br /> VIIIIl1.Count /De artment Use Only <br /> Permit F e Date slued sm g Agezlt Si afore <br /> �/ <br /> 04,Approved El Disapproved $ <br /> ❑ Owner Given Reason for Denial .00 <br /> LX.Conditions of Approval/Reasons for Disapproval C�l ! 44-7 V Q_5 <br /> APPROVEDD <br /> IE0IE0V0 <br /> !attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 1thl <br /> n si <br /> zJUL ZU19 IN <br /> SSD-6398(R0313) <br /> Burnett County <br /> Land Services Department <br />