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Industry Services Division County <br /> 1400 E Washington Ave <br /> P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> Madison,WI 53707-7162 <br /> Sanitary Permit Application State Transaction 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 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. Gl � �G� <br /> I. Application Information—Please Print All Information I , <br /> Property Owner's Name Parcel#& PU[Z <br /> Property Owner's Mailing Address Property Location <br /> t11111 � �/� Govt.Lot <br /> City,Sta e Zip Code Phone Number y., '/., Section !z <br /> 6 6' O (�trCle oneZ/ <br /> T -3 N; R !O Eor� <br /> II.Type of Building(check all that apply) Lot# <br /> I or 2 Family Dwelling—Number of Bedrooms Subdivision Name <br /> Block# <br /> ❑Public/Commercial—Describe Use <br /> ❑City of <br /> of❑State Owned—Describe Use CSM Number ❑Village <br /> VZ2 /O Town of. <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> Ig 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 /> y50 - - - - <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o <br /> New Tanks Existing Tanks c = 4, U m Z; y y <br /> a`U in y rn iL <br /> Septic or Holding Tank �rw n�y <br /> Dosing Chamber �I/[/ Wv <br /> V11.Responsibility Statement-1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> PI cr's Name(Print) / Plumber's Si _ MP/MPRS Number Business Phone Number <br /> �Af;k �5l�t5if 7IS-S�-o�o� <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 5709 <br /> VIII.Coun /De artment Use Only <br /> Approved ❑ Disapproved Permit Fee Date Issued Issuing Agent Signa <br /> ❑Owner Given Reason for Denial � /�• (►-' Z3�Z� <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> 0V <br /> Attach to complete plans for the system and submit to the County only on paper not less(ban 8 la i I inc ) y <br /> .1!.i N <br /> SBD-6398(R.08114) Burnett County <br /> Land Services Department <br />