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�y�,AttT511r1;!•.. County <br /> Safety and Buildings DivisionAl <br /> E'. <br /> D 1400 E Washington Ave Sanitary permit Number(to be filled in by Co.) <br /> P� %i P.O. Box7162 �►,, 1 <br /> �:'• Madison,W 153707-7162 <br /> Sanitary Permit Application State TransactiionnNumber <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit Cp 1499 5 <br /> is required prior to obtaining a sanitary permit. Note:Application forms for state-owned POWTS are submitted to Project Address(ifdifferent than mailing address) <br /> the Department of Safety and Professional Services. Personal information you provide may be used for secondary purposes in accordance with the Privacy Law,s.15.04 1 m Slats. 7 7 ! o L'®��i(JG/�5 f <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# o-7 6 a 0 a7 5/6/6 36 <br /> &4rr fze_A©.J 05' ®off 0/a04t5l -014 (o <br /> Property O er's Mailing Address Property Location <br /> r <br /> ®� tdJ116UQX4V 44..)hy &J Govt.Lot <br /> City,State Zip Code Phone Number y. /a, Section <br /> f u r (circle one <br /> 11 31 G T �N;_L RLt�—Eo <br /> II.Type of Building(check all that apply) Lot# <br /> �1 or 2 Family Dwelling-Number of Bedrooms -1-7 Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use ®. ❑ City of <br /> ❑State Owned-Describe Use <br /> ® CSM Number ❑ Village of <br /> V,2 ��„ J4 Town of 0,4�/�J <br /> III.Type of Permit: (Check only one box on line A. Complete line B if appli able) <br /> A. ❑New System <br /> y El Replacement System P(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 /> IV.Type of POWTS System/Component/Device: Check all that apply) <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.Dis ersal/Treatment 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 <br /> Gallons Gallons Units <br /> New Tanks Existing Tanks y <br /> a U in y v, is. C7 0, <br /> Septic or Holding-T-epk - <br /> Dosing Chamber Oj®may .�- ® 7�� <br /> VII.Responsibility Statement- I,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 s , 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) /01 <br /> (� <br /> PO BOX 514,SIREN,WI 54872 <br /> VIYI.Coun /De artment Use Only <br /> proved ❑ Disapproved Permit Fee Date Issued n ge t Si ture <br /> ❑ Owner Given Reason for Denial $ 3� 9J 2') 7)m9 <br /> k-r <br /> I%.Conditions of Approval/Reasons for Disapproval <br /> ov <br /> APPR EU <br /> n,EC� � � dC <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 111 size A U 6 ��q{' <br /> SBD-6398(R0313) r' i9 <br /> Burnett County <br /> Land Services Department <br />