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/ County <br /> + Safety and Buildings Division <br /> f p; 201 W.Washington Ave.,P.O.Box 7162 Sanitary it u (o II in by Co.) <br /> Madison,WI 53707-7162 <br /> Y�y <br /> Sanitary Permit Application State Tmns Lion Number <br /> In accordance with SPS 383.2 t(2),W is.Adm.Code,submission of this form to the appropriate governmental unit / "s O/Z/ 0 e>D 8 61-L <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 information you provide may be used for secondary UIX DetQ 4 414 <br /> purposes in accordance with the PrivacyLow,s.15.04(1 m Stuts. (7 <br /> 1. Application Information-Please Print All Information <br /> Property Owner's Name Parcel 0 <br /> cotivdie) �'d�► D <br /> Pro erty Owner's Mailing Ad Property ton <br /> vry In" Goss.Lot_ <br /> k1i <br /> State Lip Code Phone Number -A J■ ►� �, Section r <br /> k 112 md ASV? ♦ ua trcle one <br /> .Type of Building(check all that app y) a *' N: R 1�E or(9 <br /> I or 2 Family Dwelling-Number of Bedrooms Subdivision Name ���rr/// <br /> Block q <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of_ <br /> Town of <br /> DTI.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. KNew System <br /> y ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Ptumbcr ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of Po%,rS S stetn/Com onent/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)_r <br /> V.Dispersal/Treatment Area Information: <br /> Desi law ) I Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) Syst Elevation <br /> VI.Tank Info Capacity in To •a o M nufacturer <br /> Gallons Gallons Units <br /> New Tanks Existing Tacks <br /> s <br /> o, <br /> Septic or Holding Tank <br /> Dosing Chamber <br /> VII.Res onsibility Statement-1,the undersigned,assume responsibility for Installation of the POWTS shown on the attached plans. <br /> Plumber's N (Print) Plumber' MP/MPRS Number Business Phone Number <br /> Q �to <br /> PEW,A dress(Street,City,StaTe,Zip Codc) <br /> a W s ICE <br /> VIII. oun /D artmeat irseA50 <br /> Approved ❑Disapproved Permit Fec Date Issued Issuing Agent Siknaturc <br /> ❑Owner Given Reason 1 Denial $ 7 <br /> IX.Conditions of ApprovalfReasons for Disapproval f <br /> DI-ECEOVE <br /> Attach to complete pions for the system and submit to the County only on paper not less than a ra s I t lacbel IJ NIA 13 2021 <br /> SBD-6398(R. 1 I/1 I) <br /> Burnett County <br />