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• <br /> �`�'���gpna.Mr t1 <br /> \ Industry Services Division Comityjf `'l �r 1400 E Washington Avet�'` ._ i', P.O.Box 7162 11/d����n5 `` Madison,WI 53707-7162Pit Number(toff— <br /> i-c/ <br /> filled in by Co.) <br /> ;:rt ' 2i+- 1.22 <br /> 4.. 5/ 5-17 <br /> Sanitary Permit Application State Tion Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this 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 <br /> the Department of Safety and Professional Services.Personal information you provide may be used for secondary Address(if different than mailing address) <br /> purposes in accordance with the Privacy Law,s. 15.04(lxm),Stats. <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name <br /> S-jL1.4 Parcel# 4f7-3-71,5 01ew0 <br /> Property Owns Mailing Address Location L`� �z -1(>�� <br /> 2©��C1 Property I ocatioa <br /> Pa If?' <br /> e o Dr Govt.Lot <br /> City,State ,^ / Zip Code Phone <br /> Phone Numberr i <br /> �7 Yt'1l � � b [7 'Y�/ i 5 "I� (� �' "7 � ,c(..-._ '�'� /V��Y., Section � 1 <br /> 4 `i k rapply) no 6)Z— 4'�j G� circle cal0 <br /> II.Type of Building(thee that T 7 N; R 1� E o <br /> 1 or 2 Family Dwelling-Number of Bedrooms 3 Subdivision Name <br /> - <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> 0 City of <br /> ❑State Owned-Describe Use CSM Number 0 Village of <br /> ",Town of"7"f(Ji ii e_ Lc, Ye <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) 1. <br /> A. <br /> 0 New System X Replacement System 0 Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> B. 0 Permit Renewal 0 Permit Revision 0 Change of PlumberList Previous Permit Number and Date Issued <br /> Before Expiration 0Permit Transfer to New <br /> Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> ❑Non-Pressurized In-Ground 0 Pressurized In-Ground 0 At-Grade 0 Mound>24 in.of suitable soil 0 Mound<24 in.of suitable soil <br /> AHolding Tank 0 Other Dispersal Component(explain) <br /> 0 Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Desigi Flow(gpd) I Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> S j <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units 2 c <br /> New Tanks Existing Tanks w U <br /> R V rn i tA iz <br /> Septic or Holding Tank 0 VI/ w a <br /> Dosing Chamber ��[�V `__ 7r \ i C- �e `r <br /> VII.Responsibility Statement—I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Pl bee's Name(Print) ,, .o\-f- e, cPlumb i <br /> j C'� f/ MP RS Number Business Phone Number <br /> Plumber's Addr'ess(Street,City,State,Zip Code) /��7G � _J <br /> W <br /> VIII.County/DepartmentCUs fin �Lcl P- oedi T ` e /l �N I 5�Pt. <br /> $ <br /> Approved 0 Disapproved Permit Fee Date Issued Issuing Agent Signature <br /> -7 <br /> 0 Owner Given Reason for Denial 7S S�4• 74 l 1 <br /> IX.Conditions of Approval/Reasons for Disapproval GJ Af <br /> CM E Db$� $i3Z 5 <br /> �1 K fcA�#f D E © t I V l5 �1 <br /> Attach to complete plans for the system County only on paper not less than 8 1/2x11 I <br /> size <br /> MAY 1 2 2021 <br /> SBD-6398(R.08/14) Q"!2( A c— Burnett County <br /> Land Services Department <br />