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N <br /> y_ ,;xr E;r;,, County <br /> f '' NI-\ industry Services Division IL.0 Pt t°tl <br /> :0 1400 E Washington Ave Sanitary Permit Number(to be tilled in by Co.) <br /> ,a ,,,, .P,., 1 1 P.O. Box 7162 5A-N "21��9 <br /> '43� '. <Q.. rk t Madison,WI 53707-7162 <br /> ,-.4-;-::- _::P. 3 7 ZG <br /> e: CST-2i - /7b <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 d 9 ot d,S" <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. Cep go/ /l <br /> I. Application Information-Please Print All Information _ <br /> Property Owner's Name Parcel# ,-,10../6,/.e" -s'o$d o s- <br /> Pitf- P i c. k <br /> 01-OAS"' <br /> oaJ/cob <br /> 31m0 <br /> Property Owner's Mailing Address Property Location <br /> 8// ParK P/Ace 0r. Govt.Lot <br /> City,State Zip Code Phone Number /, /, Section y <br /> 114we�'►Gfo7-G #(1)14..15.'tII( 8 (circle one) <br /> II.Type of Building(check all that apply) Lot# T �/O N; R /y E otg) <br /> •l or 2 Family Dwelling-Number of Bedrooms Ga'"'te--"''f� Subdivision Name <br /> •Y"e t/4 Block# <br /> • <br /> ❑Public/Commercial-Describe Use ❑ City of <br /> CSM Number 0 Village of <br /> ❑State Owned-Describe Use <br /> lif Town of .SLo <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. nNew System y 0 Replacement System 0 Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> B ❑ Change ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> ❑ Permit Renewal ❑Permit Revision of Plumber <br /> Before Expiration Owner <br /> IV.Type of POWTS,System/Component/Device: (Check all that apply) <br /> Yr:IsTifiii.74§0Yed In-Ground 0 Pressurized In-Ground ❑ At-Grade 0 Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> 0 Holding Tank ❑Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> V Dispersal/Treatment Area Information: <br /> DesgnFlow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> /SD , —7 d/s— )15-0 93. 0 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> r. <br /> Gallons Gallons Units `o 'o U <br /> New Tanks Existing Tanks 1 i' aj .~n F �'� <br /> 0 <br /> a U vt y cn 4:,-3 a <br /> 116E Septic or Holding Tank •y D 5110 / =h F%!,i YII .O <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 PhonePh/`Number <br /> /Of ale /�/ 414 t /0e.a.. /4/7„4.1. )0(.58..r/ 7i-f Gam'- 907 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> .2 7-7/ 6o IA..) .3s'_' Lv-G‘>Yr r 1iti..7-- _STO!.r. <br /> VIII.County/Department Use Only4pproved ❑ Disapproved Permit Fee Date Issued u' A tSigna /i' lip <br /> ❑ Owner Given Reason for Denial 3 S3,-C: roororf-_,....0/ <br /> IX.Conditions of Approval/Reasons for Disapproval :70317 .f.� <br /> a ECEUVE ----1 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 I/2 s l Ih In siJ L 2 6 202• J/ <br /> Burnett County <br /> SBD-6398(R0313) Land Services Department <br />