Laserfiche WebLink
r+aeT <br /> lttdustryServicesDivisioa <br /> 1400 E Washingtow,Ave <br /> r �� c Z P.O.Hex 7162 Permit N (to be filled mnbyoC ) T <br /> J011 `. Madison,Wt 53707 7162 <br /> tate <br /> Sanitary permit Application S Ttatnactialt Number t0�/ <br /> In accedence wit),SPS 3g3 21(2),Wis.Adm.Cods,arbmission of this forth to the ap"Wiate govern--w—1 __-addrrss} <br /> r--- <br /> is mquirW prior to ohta m+g a sanitary permit-Note Application Iona ter'staoe-awned POWTS are submitted to Pmjoct Addros(if diffannt tbru mailing <br /> i the of Safety and Protkaaional Services-Pbtwma►inft natim you provide may be used for secondary <br /> Duninew in accordance with the s.15. t m Sails { FA W f�) i,Q J�E bRi d <br /> I. Lfot'a aDis-Pfeasc Print AN Lfenwtiea <br /> Property Owner's Name Panuxl# 47'O5 L <br /> �� ��t��c!J <br /> f Ll 0 S JAM property Location <br /> property owner's Mailing Address <br /> g W COO c rzUS't RO�+D c,OVt.to <br /> city,stab zip code Phone Nimiber — '/. - '/., Section 3 <br /> ram!! (clink one <br /> W R l TEE LAKE T III N; R !5 E or W <br /> II.Type of Banding(chak all that apply) Lot# <br /> Subdivision Name <br /> xI or 2 Family Dwelling-Number of Bedrooms .J gyp. <br /> Bled[# /V7 <br /> D PubiiclCommaoial-Describe Use -` ❑city of <br /> ❑State owned-Descnbe Use CSM Number ❑Village of 1 � <br /> XTbwn of Si,V is <br /> III.Type of Perms (Check only erne box at line A. Complete Irate B if applicable) <br /> A. %New System ❑Replace mart System ❑Treatmen0jokling Tank Repta_wd Only ❑Other Modification to Existing Systtan(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑Cbange of Plumber ❑Permit ThIII to New List Previous Permit Number and Date Issued <br /> Betcee Expiration Owner <br /> M Type d PIS Cbeck all that <br /> PtNon-ftc=Wed kWko ad ❑Pressurized I:r� ❑At-Grade D MouW>2,4 cm.of 1c sail ❑Motetd<24 in.of stdtabk soil <br /> D Hd&*Talc ❑Other Dispersal Campooau(explain) ❑Pretreatmcr9 Device(explain) <br /> V.Dispervonreatmest Area Lforassiden• <br /> Design Flow(gpd) Design Sod Appl-Mort Ra*gpdst) Dispersal Ana Rotpuinmd(sf) Dispersal Area Proposed(sf) System <br /> 614 L r6& <br /> VI.Tank We Capacity in Total #of Manufacpaer , <br /> Gallons Gallons Units A s $ v <br /> New Tales 55tt <br /> Exi"Tacker a U 1 i w U <br /> septic ae44dmmgzeaic. /D ( 5rW- NrL r" TL'7 <br /> 0-18� I—H <br /> VII. Statement-1,dir aaderekaei,a lar irraftska,of the POWTS dwim oa the attacmd Plana <br /> Plumber's Now(Print) $' <br /> MHM+�RB�Nunbex Bembneas Phone Number <br /> Plmmibcr's Address(str«1,city,state,zip code) <br /> 934, OjiAcrK BRCeK RD, wF,s sri—eiQ ";2 Sq gq3 <br /> VIII.Cate t Use Only <br /> �gpproved D Diapproed "emit Fee Dade IssuCeed Issuing tAgcnt SigrMtffe <br /> D Owaa Given Reason for Denial <br /> /n/(J <br /> UL Coaditim of ApprsvaliReasoas for Disapproval <br /> Atimei to e@=I pi...ter tt..., err&MI So tt..Casty adr an popw t mere : <br /> APR 0 5 2021 <br /> SBD-6398(R 08/14) <br /> Burnett County <br /> Land Services Department <br />