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='"- Industry Services Division County <br /> 1400 E Washington Ave <br /> psi es <br /> P.O.WI x 7162,7162 Sanitary Permit Number(to be filled in by Co.) <br /> '$ Madison <br /> sp-N-at—,224 <br /> -I �37LG <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. <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> Aired 40ou <br /> Property Owner's Mailing Address `,,' Property Location <br /> f/5 O /'��f�/t+v t 4�]0 Govt.Lot <br /> City,State Zip Code Phone Number y, %4, Section ?-119 <br /> cI le one <br /> T N; R 17 E o <br /> II.Type of Building(check all that apply) Lot# 61 <br /> ❑ I or 2 Family Dwelling-Number of Bedrooms Z 1417- Subdivision Name <br /> Block# L Ae �4.AJ he, <br /> ❑Public/Commercial-Describe Use -,1- ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of <br /> [ZTown of U IV.O.,V <br /> 111.Type of Permit: (Check only one boa 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 /> 3ov -ls �3 z �L: 6 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units c v <br /> New Tanks Existing Tanks <br /> E o - 2 —v a s a <br /> a U CA y to ii t7 a <br /> Septic or Holding Tank 7TO <br /> Dosing Chamber -00 <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> P1u cr's Namc(Print) Plumm s Signature MP/MPRS Number Business Fhonc Number <br /> Plumber's Address(Street,City,State,Zip Code) <br /> G 8t Avoh w C A W/ tve6r2/,el- vI 5y89 <br /> VIII.County/ e artment Use Only <br /> / L <br /> Approved ❑ Disapproved $etmit Fee Date Issued i Age tSignatur <br /> ❑Owner Given Reason for Denial 37S �� Z� <br /> VL <br /> IX.Conditions of Approval/Reasons for Disapproval M <br /> [P= ' <br /> E l/ <br /> D k�9 <br /> Attach to complete plans for the s}stcm and submit to the County only on paper not less than 8 In- ie ie <br /> Burnett County <br /> 1 a SBD-6398(R.08/I4) Land Services Department <br /> � <br />