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i�,krnsrar� <br /> Industry Services Division County <br /> S 1400 E Washington Ave f <br /> P1 :. Sp F,, P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> .'t S Madison,WI 53707-7162 <br /> ::.,.. : G 3 7 C3 9 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this foam to the appropriate governmental trait <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 <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Slats. <br /> I. Application Information-Please Print All Information 2 79 �•Q Vi <br /> Property Owner's Name At-he, <br /> Parcel# 7 y <br /> jand 04;1"-f7Z-02=00 <br /> Property Owner's Mailing Address V Property Location <br /> ZM84 <br /> 6wew Govt.Lot <br /> City,State -- {{ Zip Code Phone Number � %, Section <br /> wi 5�T D7Z rcle one <br /> T N; R�Eeo� <br /> II.Type of Building(check all that apply) Lot# <br /> I or 2 Family Dwelling-Number of Bedrooms /f t� Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of <br /> Town of Aee4VO/V <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <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 List Previous Permit Number and Date Issued <br /> g ❑Permit Transfer to New <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.Dispersal/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 ' L c v <br /> New Tanks Existing Tanks <br /> a U in y Os ii 0 a <br /> Septic or Holding Tank <br /> Dosing Chamber ?"KJ �.L• <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for Installation of the POWTS shown on the attached plans. <br /> P crZ 's Name(Print) / Plumbcr' ' nature MP/MPRS Number Business Phone Number <br /> lu <br /> azo <br /> Plumber's Address(Street,City,State,Zip Code) <br /> G 8/ Avoh w IA 4/ tiJebtil-er U,• 5 709 <br /> VIII.County/ e artment Use Only <br /> -pproved 11 <br /> ❑Disapproved Permit Fee Date Issued 9g gem i <br /> ❑Owner Given Reason for Denial $ / �' p Z� <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> ia-E (D E 0 V A F�) <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 In-s in size <br /> JUN 2 9 2021 Ul <br /> SBD-6398(R.08114) Burnett County <br /> Land Services Department <br />