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r rtl+ County <br /> 1 Safety and Buildings Division G1�� <br /> y 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> " P.O.Box 7162 t <br /> N Madison,WI 53707-7162 <br /> Sanitary Pen-nit t pplicatio� State Transaction Number <br /> 7n 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 L/� �-y <br /> oscs in accordance with toe Privacy Law,s.15.0 1 m,Stats. 7 / <br /> ' a. Apipfication Information-Please Print All Information 2-/9Lr r <br /> Property Owner's Name Parcel# <br /> Q f <br /> P:ooerry Owner's Mailing Address Property Location C <br /> 5 5�9 `� L,/ J 2 .tJ c�✓ Govt Lots <br /> t•,State Zip Code Phone Number /, % Section <br /> � J t / / 11,q <br /> rq �...L 5Oo241 X5/��02 d0o/ T N R /J i-leon <br /> it y�e of Bonn➢ding(c➢neclk all➢that apply) Lot# E +A/ <br /> or 2:airily?�vreli ng-Number of Bedrooms �" Subdivision Name <br /> _ Block# <br /> Pubic/:'ominercial-Describe Use <br /> ❑City of " <br /> } CSM Number El Village of <br /> Sta_tc Owncd-Describe Use <br /> r <br /> O Town of 4,',i­�r <br /> HILL i yfre of Fer-onk: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> !J New System replacement System Q Treatment/Holding Tank Replacement Only ❑Other Modification to Existing Sys <br /> tem <br /> explain) <br /> m Y 'c: {e-P ) <br /> J• Q Permit Renewal I Q Permit Revision Q Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration I Owner <br /> 1 T T.'T Ie of POWTS System/Component/Device: (Check all t➢tat a 1 <br /> on-Pressurized In-Ground ❑ Pressurized In-Ground Q At-Grade ❑Mound>24 in.of suitable soil El Mound<24 in.of suitable soil <br /> Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> 1 VT DispersaY. Treatmment Area Information: <br /> l Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> go a 333 3 333 y� 9 <br /> Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o y <br /> Ncw Tanks Existing Tanks w o N y <br /> a <br /> a U �n cn w C7 w <br /> I Septic or±ieiding_ee r e/e <br /> Dosing Chamber � r_O s� r„ ` <br /> i <br /> Responsibi➢ity Stateirnent- Y,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Se MP/MPRS Number Business Phone Number <br /> i `SiADE?UFSIIOLM �//J 227691 715-349-7286 <br /> ?lumber's Address(Street,City,State,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 <br /> i <br /> WIFE County/Department Use Only <br /> �. pproved i Q Disapproved Permit Fee Date Issued Issuing Agent ignature <br /> Q Owner Given Reason for Denial / Jam'Z�(.• L/ <br /> Conarlitions of Approval/Reasoas ffor Disapproval <br /> D V <br /> IMAY 19 2021 <br /> dttaieh to complete plans For the system and submit to the County only on paper not►ess than 8 l s 11 i hes in size <br /> SBD-5398 IZ0313) Burnett County <br /> Land Services Department <br />