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County ,? <br /> Industry Services Division ,GJG1 pia e 1174 <br /> 1400 E Washington Ave <br /> V. <br /> 9 Sanitary Permit Number(to be tilled in by Co.) <br /> s ` ` P.O. Box 7162 <br /> Madison,WI 53707-7162 <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 Servies. Personal information you provide may be used for secondary of 7�7 C�FG� <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Slats. <br /> I. Application Information—Please Print All Information <br /> Property <br /> C�Owner's Name Parcel# Cs oo i <br /> /�+.. lee SO t, v7-Olaf—ol—�—/,$=ot8 S— <br /> a 12 0OZ7 SS o�- <br /> Property Owner's Mailing Address Property Location <br /> e7 1 Govt.Lot 404 <br /> City,State Zip Code Phone Number y, '/,, Section ,z <br /> p p f (turtle one) l <br /> II.Type of Building(check all that apply) Lot# <br /> Jfl I or 2 Family Dwelling—Number of Bedrooms Subdivision Name <br /> Block# V'..S P «y <br /> ElPublic/Commercial-Describe Use ❑ City of <br /> ❑State Owned—Describe Use CSM Number ❑ Village of <br /> gTownof JeLcAfSet-1 <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A* A New System <br /> y ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B• ❑ Permit Renewal ❑Pennit Revision Change of Plumber El Transfer to New List Previous Permit Number and Date Issued <br /> ❑ <br /> Before Expiration Owner <br /> IV e of POWTS.S stem/Com onent/Device: (Check all that apply) <br /> Non-Pressurized In-Ground ❑ Pressurized fn-Ground El At' El Grade 24 in.of suitable soil El Mound<24 in.of suitable soil <br /> ❑ HoCiim�Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V Dis`d'I/Treatment Area Information: <br /> Des gu`>li w(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> VI.Tank Info Capacity in Total #of Manufacturer v <br /> Gallons Gallons Units o o <br /> New Tanks Existing Tanks 2 Y <br /> n.U 2 Cn u C7 a <br /> Septic or Holding Tank /� f S <br /> Dosing Chamber.. l !O <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) <br /> VIII.Court /De artment Use Only <br /> Approved ❑ Disapproved Permit Fee Date Issued Issuing Agent Signature <br /> i <br /> ❑ Owner Given Reason for Denial 37S /1 L�. <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Qn --- <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 t/2 x I I he siz <br /> v <br /> SBD-6398(R0313) Burnett County <br /> Land Services Department <br />