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"';� Industry Services Division County <br /> ii-7. �; 1400 E Washington Ave Ou the' <br /> l;;, <br /> PI .. $p P.O.Box 7162 SanitaryPermit Number(to be filled in by Co.) <br /> t, ; $ Madison,WI 53707-7162 SOW 2/-83 <br /> \z' = CST,?! -Se 3S/ ZD <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. I �� y <br /> I. Application Information-Please Print All Information 5 77 <br /> Property Owner's Name Parcel# -./3 31 <br /> /im 7,fiei 07,72-2-q/-/5-175oc-t22-offal . <br /> Property Owner's Mailing Address Property Location <br /> i2 () 4>4 4/'70e LN Ai Govt.Lot Z <br /> City,State Zip Code Phone Number t14 /7 <br /> M �w ih wv, C5�1// /,, Section <br /> //'// ''�[/ J /� crrcle oL& <br /> II.Type of building(check all that apply) Lot# T 7 N; R E o �1/ <br /> +I or 2 Family Dwelling-Number of Bedrooms 2 Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> 0 City of <br /> ❑State Owned-Describe Use CSM Number0 Village of <br /> Vi8 /(!/n j�l�✓9 % i'j <br /> Town of ' ' <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> 0 New System '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 PlumberList Previous Permit Number and Date Issued <br /> 0Permit Transfer to New <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> GrNon-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.DispersallTreatment Area Information: <br /> Design Flow gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System levation <br /> 7VV <br /> .7 V of 1132 7.709'/.7#444919#.() <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> u <br /> Gallons Gallons Units c v <br /> New Tanks Existing Tanks at= _ r, a, y H <br /> Eo 2 . .o ea <br /> et u in y in is. 0 a <br /> Septic or Holding Tank RV() <br /> Dosing Chamber G�Vira, 2 O li 4 <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for installation of theeeePOWTS shown on the attached plans. <br /> Plu cr's Namc(Print) / Pltunbe ignatureMP/MPRS Number Business Phone Number <br /> 'j011Q l�/ � ✓ 861952/52/ 7IT-sg-02o2 <br /> Plumber's Address(-Street,City,State,ZipCode) <br /> 6681 Ile / 1 kle6� L ,' 511$93 <br /> VIII.County/Department Use Only <br /> pproved ❑Disapproved Permit Fee Date Issued Issuing Agent Signature <br /> ❑ Owner Given Reason for Denial 7,57 4I 2` . 7/ j. <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Ck&t la5sL $qac <br /> t <br /> Attach to complete plans for the system and submit to the County only on paper not less than 81a_s 11 Ih size <br /> J <br /> APR 2 0 2021 <br /> - <br /> SBD-6398(R.08/14) - Burnett County <br /> Land Services Department <br />