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•;i,;;rrtirr,r, County <br /> 1 . Safety and Buildings Division N r'/) e„.../F. <br /> a - 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> IZi P.O.Box 7162 <br /> ' Madison,WI 53707-7162 �JR1J'o7-0 ���` <br /> • �. :,;.......„4.:•,,' 4T-,:10 - IV) <br /> Sanitary Permit Application State TransactionN3jumber <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit <br /> I�O <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 az/ 7� <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. 11 ( <br /> I. Application Information—Please Print MI Information 1.410;i ,/rt.' e_ Tti4// <br /> Property 0ner's Name r, I Parcel# 0.7 0 j (/ ,Z 3715/12 <br /> /YIi e L_ Vier/ -5" /3' `>5/L 0;z`>6nn <br /> Property Owner's Mailing Address] ,, r Property Location 135318 <br /> /A 2/ l,,), in eel//(..Po Z-11-to .6 rN Govt.Lot <br /> { <br /> City, <br /> State Zip Code!/ / Phone Number C� y, %<, Section f�' <br /> fll ,7% /77 '0 J`���T( 0.01-4a7g�/8 y. (circle one <br /> T .3 7 N; R tk E W <br /> ]It. .ype of Building(check all that apply) Lot# <br /> .54 or 2 Family Dwelling—Number of Bedrooms _5 / 2 Subdivision Name P/i1-•f"e0-E <br /> ^�_ <br /> mBlock# 1 S� ///()e5 Cil' ii^i t Lk. <br /> ❑Public/Counercial—Describe Use - <br /> 0 City of <br /> r •...—�' CSM Number 0 Village of ' <br /> i_1 State Owned—Describe Usc <br /> �— p-Town of '77-4"l" 1-,4 K _, <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. gNew System 0 Replacement System yp y 0 Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> E. 0 Permit Renewal 0 Permit Revision ❑ Change of Plumber 0 Permit Transfer to New List Previous Permit Number and Date Issued <br /> 1 Before Expiration Owner <br /> IIT.Type of POWTS System/Component/Device: (Check all that apply) <br /> Ton-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade 0 Mound>24 in.of suitable soil 0 Mound<24 in.of suitable soil <br /> Holding Tank 0 Other Dispersal Component(explain) 0 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 /> vE.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units °3 o b <br /> New Tanks Existing Tanks o� 2 -S ro <br /> Septic or Belding Ts /JD C/ /0e4) / 41/ ,e___5 E" / "74- <br /> f Dosing Chamber <br /> i <br /> VII. r esponsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature <br /> Number Business Phone Number <br /> WADE RUFSHOLM /A .- 21� 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) 6J' / /� �<+�— <br /> I PO BOX 514,SIREN,WI 54872 <br /> 1 VII:T[i.County/Department Use Only / <br /> pprovcd ❑ Disapproved Permit Fee Date sued mg Ag t Sip�natur _ <br /> �' °, 9Ga <br /> I 0 Owner Given Reason for Denial , <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> : o "IIJ [ � E�_ _ E1; rKuf bKoa511 e oeol�af <br /> OHLiGo�Dr ' <br /> Hf�cl7444."( <br /> llfL/L64 ill OR roof ad weak(DraihA!d i SEP 15 2020 <br /> Attach to complete plans for the system and submit to theCounty only on paper not less than 8 lizA ll i es in size <br /> l✓ 7 <br /> SBD-6398(R0313) 1 Burnett County <br /> I Land Services Department <br /> Opp' 153 4`-i a5 <br />