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�tt�a_u <br /> Industry Services Division County <br /> 1400 E Washington Ave �N <br /> I S p = P.O.Box 7162 Sanitary Permit Number(to be filled in by Co. <br /> .'� S Madison,WI 53707 716261 f� <br /> ._ W al - z <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 38321(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit <br /> is required prior to obtaining a sanitary permit.Note:Application fomu 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 U 6 Z <br /> purposes in accordance with the PrivacyLaw,s. 15.04(t)(m),Stats. <br /> I. Application Information—Please Print All Information <br /> Property Owner's Name Parcel# <br /> q/VA) *4- -a <br /> Property Owner's Mailing Address J�� I/ Property Location <br /> ,',t <br /> ` 4,. /e Govt.Lot <br /> City,State Zip Code Phone Number y, ,�,, Section <br /> eWe� W. Sy�3 T yo N: R�IEK <br /> II.Type of Building(check all that apply) Lot# <br /> �� <br /> �F1 or 2 Family Dwelling—Number of Bedrooms T Subdivision Name <br /> Block# <br /> ❑Public/Commercial—Describe Use ❑City of <br /> ❑State Owned—Describe Use CSM Number ❑Village of <br /> U 5 OP�7 Town of AJ <br /> III.Type of Permit: (Check only one boa on line A. Complete line B if applicable) <br /> A. <br /> ❑New System F Replacement System ❑Treatment/Holding Tank Replacement Only ❑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.Type of POWTS S stem/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 /> 19 Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Deice(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flo%v(gpd) Design Soil Application Rate(gpdsf) r <br /> ispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 4,U <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units ' U <br /> New Tanks Existing Tanks w u y <br /> is. <br /> Septic or Holding Tank ` zav t <br /> Dosing Chamber VK/ <br /> VII.Responsibility Statement—L the undersigned,assume responsibility for installation of the POWTS shown on the attached plans <br /> Plu is Name(Pri nt)k <br /> Plumber's re MP/MPRS Number Business Phone Number <br /> /f�l(Qi �.f/�1 ��! 5-7 71�-S6�-aZoZ <br /> Plumber's Address(Street,City,State,Zip Code) <br /> VIII.Court /De artment Use Only <br /> ❑Approved ❑Disapproved PermitP5. <br /> Date Issued ^^ Iss ' g t Signa <br /> ❑Owner Given Reason for Denial S 3 �11! f <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> no EC EBYF <br /> Attach to complete plans for the system and submit to the County only on paper not less than 9 If nlies in size <br /> - - <br /> SEP 1 1 3 2021 <br /> �� l �6G <br /> SBD-6398(R 08/14) Burnett County <br /> Land Services Department <br />