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lill'/.R;i.i17::'p•:`.. County_ <br /> Safety and Buildings Division �. r <br /> u' 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co <br /> P.O.Box 7162SPVJ _I`1 <br /> v;. Madison,WI 53707-7162 <br /> Sanitary Permit Application State Transaction Number p <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit /-W <br /> is required prior to obtaining a sanitary permit. Note:Application forms for state-owned PO WTS 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 I m,Stats. <br /> II. Application Information—Please Print A➢➢Information <br /> Property Owner's Name Parcel# Q '7 0 r2, 9 �z 61 z) f <br /> 1-6,Cie-] P r -S—c 1 p p- d C C <br /> Property Owner's Mailing Address Property Location c, <br /> 3 0 �' �j i i �/",/�{ � I Govt.Lot !/ <br /> City,State Zip Code Phone Number /4 /4, Section—Z 7 <br /> Aft G 1 1 SD 7 (circle one) <br /> KJ T 51� _N; R EorW <br /> 11.'II'ype o uflding(check all that apply) Lot# <br /> 9'11 or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use ❑City of <br /> CSM Number ❑Village of <br /> ❑State Owned-Describe Use / <br /> ( / f j Mown of ��- <br /> IHII.Type of Permit: (Check only one box on line A. Complete line B if app cable)/ <br /> A. <br /> ❑New System Replacement System ❑Treatment/Holding Tank Replacement Only Other Modification to Existing System(explain) <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 /> IIV.Type of POWTS System/Component/Device: Check all that ap <br /> ❑Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil 9 Mound<24 in.of suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.II➢is ersai/Treatulent Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> VI.Tank Info Capacity in Total #of Manufacturer y <br /> Gallons Gallons Units ? v <br /> New Tanks Existing Tanks o y m <br /> a U <br /> Septic or Holding Tank <br /> Dosing Chambers <br /> VIIII.Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWT'S shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> WADE RUFSHOLM 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 <br /> VIIIIII.Coun /IIDe artment Use Only <br /> Approved El Disapproved Permit Fee Date Issued Issuing E C E ��Vn E <br /> El Owner Given Reason for Denial <br /> ltl� <br /> IX.Conditions of ApprovaVReasons for Disapproval <br /> MAY 15 2019 UU <br /> A?P R 0*4 V[ out BURNETT COUNTY <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 inchZn stze <br /> NG <br /> SBD-6398(R0313) <br />