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County <br /> Industry Services Division <br /> 1400 E Washington Ave Sanitary Permit Number(to be tilled in by Co.) <br /> P.O. Box 7162 <br /> Madison, WI 53707-7162 <br /> . :� 37t y� <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 Servies. Personal infonnation 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 l�un td�.�pfnateh !Z� . <br /> Property Owner's Name Parcel# <br /> Nteck o-1-0o(o_d-3JP-17-1a-1-a3- o Io <br /> Jo 4" zaZ�7 - 011000 <br /> Property Owner's Mailing Address Property Location <br /> 401 Old J4&p1e&,j.5 I-C <br /> Govt.Lot <br /> City,State Zip Code Phone Number , <br /> /<, Section �02 <br /> �k�flh Sy�l6 8 circle one <br /> T 3 N; R 1 / E or( <br /> I1.Type of Building(check all that apply) Lot# <br /> m I or Family Dwelling—Number ofBedrooins 3 Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use ❑ City of <br /> ❑ CSM Number ❑ Village of State Owned—Describe Use <br /> Town of <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. )�New System <br /> y ❑Replacement System ❑Treatment/Holding Tank Replacement Only El 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.''i " e.of POVyTS.S stem/Corn onent/Device: (Check all that apply) <br /> Q on Pre razed In-Ground ❑ Pressurized fn-Ground ❑ At Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> [{ofdin=Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> saI/Treatment Area Information: <br /> D6s guM(gpd) Design Soil Application Rate(gpdsfl Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o <br /> New Tanks Existing Tanks o �, 2 Y a ro A <br /> c U <br /> Septic or Holding Tank -e/-V 19 p0 0 <br /> Dosing Chamber.. t <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the PObVTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> 8L6—Z /S7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> VIIl.Coun /De artment Use Only <br /> Approved ❑ Disapproved Permit Fee Date[sued Issuing Agent Signature _ <br /> ❑ Owner Given Reason for Denial $ 37S I 7.4 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> D <br /> JUL 13 M, _DIU. <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 s 1I -aches ir size <br /> Burnett County <br /> Land Services Department <br /> SBD-6393(110313) <br />