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Industry Services Division County guineit. <br /> " 1400 E Washington Ave <br /> , ' 0 'i P.O.Box 7162 S -a{p��P�etn, it Number(t2.be filled in by Co.) <br /> IsI , S _ �1�1 —aL l �f <br /> � Madison,WI 53707-7162 <br /> \ 4(2 6 y'C7 c5-at- .2$5. <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 Services.Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. �� ���� <br /> I. Application Information-Please Print All Information G <br /> Property Owner's Name Parcel# <br /> l <br /> Property Owner's Mailing Address Property Location <br /> 47/11Nd(AAJ Le/ / �I4 <br /> Govt.Lot <br /> City,State �f/J�/ Zip�CodePhonePhone Number y,, /4, Section 7 <br /> i///� ✓ v �3 T N, It f�rcleE oneE oraII.Type <br /> kleAm <br /> ilding(check all that apply) Lot# <br /> WI or 2 Family Dwelling-Number of Bedrooms , /6 Subdivisio ame <br /> Block# 1 ific eig ? <br /> ❑Public/Commercial-Describe Use <br /> 0 City of <br /> ❑State Owned-Describe Use CSM Number 0 Village of <br /> (Mown of 04 k.k,,, <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. 0 New System y Replacement System 0 Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> B. 0 Permit Renewal 0 Permit Revision 0 Change of Plumber 0 Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> /Non-Pressurized In-Ground 0 Pressurized In-Ground 0 At-Grade 0 Mound>24 in.of suitable soil 0 Mound<24 in.of suitable soil <br /> ❑ Holding Tank 0 Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System l.vation <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o 'n u <br /> 9. <br /> New Tanks Existing Tanks o u 2 6 . z ca <br /> aU rn y cis tz. 5 a <br /> Septic or Holding Tank WOO 'JO/O ! � <br /> Dosing Chamber WOO wv <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plu cr's Name(Print) Plumber's ature MP/MPRS Number Business Phone Number <br /> Of* f,d9Adft <br /> 861 9 5-7-/ 7/5---'56d-eszoz _ <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 6&61 AM Al Ile it we icier t„/1' 51/69, <br /> VIII.County/Department Use Only <br /> Approved 0 Disapproved Perm.t Fee e0 Date Issued <br /> sued 4ui•2 At nt Si v(.i - .�� <br /> 0 Owner Given Reason for Denial g 91' / /� <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> iz. 7.- <br /> CM al70 54.25 <br /> • <br /> t © VlT <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 in a in size <br /> SEP 7 2021 / <br /> SBD-6398(R.08/14) Burnett County <br /> Land Services Department <br />