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County <br /> Industry Services Division <br /> _ # 1400 E Washington Ave <br /> 9 Sanitary Permit Number(to be filled in by Co.) <br /> P.O. Box 7162 <br /> L ,A 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 �7 <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Slats. I v 7� ,dG r <br /> I. Application Information—Please Print All Information W• Y-ell'o w, Aw <br /> Property Owner's Name Parcel <br /> Property Owner's Mailing Add ess Property Location <br /> a 87W <br /> Govt.Lot <br /> City,State Zip Code Phone Number y, '/,, Section <br /> De-11 64AY1 1,6 11 J 0 Lc E or <br /> one) <br /> II.Type of Building(check all that apply) ? Lot# T YIV N; R /G <br /> �1 <br /> Nr I or 2 Family Dwelling—Number of Bedrooms .J T Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> ❑State Owned—Describe Use CSM Number 0 Village of <br /> ® Town of 04C IIC I...e' <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> ❑New System 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 /> mlype.of POWTS S stem/Com onent/Device: (Check all that apply) <br /> DZVo`a:Presss"prized In-Ground ❑ Pressurized f a-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.ofsuitable soil <br /> ❑ Holdin�Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V Dis `Aral/Treatment Area Information: <br /> Design'Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(st) Dispersal Area Proposed(sf) System Elevation <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o <br /> New Tanks Existing Tanks <br /> B o =f n � <br /> aU m y C13 cr_u a. <br /> Septic or Holding Tank G d 4*11 o / 7 y, <br /> N ittOr <br /> Dosing Chamher <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POIVYTS shown on the attached plans. <br /> Plumbers Name(Print) Plumber Signature MP/MPRS Number Business Phone Number <br /> J7i4 lc /s zi e r 9,$—/ 71U= 8 G6 <br /> Plumber's Address(Str et,City,State,Zip Code) <br /> FIXIC-Condlitloms <br /> oup /De artment Use Only <br /> ved ❑ Disapproved Permit Fee bate Issued u' A nt Signatur <br /> ❑Owner Given Reason for Denial <br /> of Approval/Reasons for Disapproval 7 J5 <br /> 45— <br /> 1010 <br /> nIEC OWIE <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/I x I I 1 11size <br /> Burnett County <br /> SBD-6398(R0313) Land Services Department <br />