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County <br /> Industry Services Division !3/,t✓'n +=71Y <br /> 1400 E Washington Ave SnAtary Permit N> ber(to be tilled in by Co.) <br /> P.O. Box 7162 <br /> Madison,WI 53707-7162 a <br /> s - t _6 431 1Y.1y <br /> Sanitary Permit Application StaatteTra4actionNumber <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit �`-'' �� DDD G�-L <br /> is:required prior to obtaining a sanitary permit. Note:Application forms for state-owned POWTS are submitted to Project pAddress(if different than mailing address) <br /> the Department of Safety and Professional Servies. Personal information you provide may be used for secondary d O d b3 S• Joti y sa h �/[ <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Slats. <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> Oos- Dd 7000 <br /> Property Owner's Mailing Address y� l Property Location <br /> 95 61Are�,GC /I've- J� Govt.Lot b <br /> City,State Zip Code Phone Number / y,, Section 3 <br /> Is /tit A/ ,j s L.�/ � (circle one) <br /> I1.Type ot Building(check all that apply) Lot# <br /> T N; R /b E orp <br /> ® l or 2 Family Dwelling-Number of Bedrooms 3 3s' 36 7 Subdivision Name <br /> Bloc # <br /> ❑Public/Commercial.-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use <br /> CSM Number ❑ Village of <br /> ® Town of 04 l6/a n GP• <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑New System <br /> y ®Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other ivtodification to Existing System(explain) <br /> B- 0 Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV..T: e.of POWTS.Sys tem/Com onent/Device: (Check all that apply) <br /> ❑rNori'Pz zed In-Ground ❑ Pressurized In-Ground ElAt Grade ❑ Mound>24 in.of suitable soil ® Mound<24 in.of suitable soil <br /> it y p _ <br /> ❑ Flo&d Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> VS1Ds ersal/Treatment Area Information: <br /> Desfgi T16w(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sfl Dispersal Area Proposed(st) System Elevation <br /> v-So J. Id yso o y <br /> VT.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units ;, 0 9 0 <br /> New Tanks Existing Tanks <br /> e U on m R0 0. <br /> Septic or Holding Tank <br /> poo /Ddo <br /> Dosing Chamber <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 /> /F/G/L llap klh c� ,!S"8s�� 7is=g66 --Z/i s <br /> Plumber's Address(Stye t,City,State,Zip Code) <br /> 76 0 41 3.s- 6sfrr Gr�T S �3 <br /> VI11.Coun /De artment Use Only <br /> Approved El Disapproved Permit Fee Date Issued Issuing Agent Signature _ <br /> El Owner Given Reason for Denial $ �J7,J z'-r 2 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> qLECCOM [E <br /> Attach to complete plans for the system and submit to the County,only on paper not less than 8 1/2 x 11 1 heff size <br /> Burnett County <br /> SBD-6393(R0313) Land Services Department <br />