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Installed°, N <br /> E 'I , c uot Safet and Buildings DivisionCounty <br /> 201 W.Washington Ave.,P.O.Box 716213u(Nedi- <br /> isconsin Madison,WI 53707-7162 <br /> Sanitary Permit Number(to (� 1 fikle i�b o.) <br /> Department of Commerce {608)266-3151 �1),4-KI-(33 <br /> Sanitary Permit Application State Plan I.D.Number — <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide <br /> may be used for secondary purposes Privacy Law,s15.04(1)(m) Project Address(if different than mailing address) <br /> I. Application Information-Please Print All Information �. <br /> 67/3 F-/owa�e JIr <br /> Property Owner's Name Par I# Lot Block# <br /> G'Pive Novrtk o7-v3z-z /-4 ' S Ps 357-outwo <br /> Property Owner's Mailing AddressAdProperty Location 2 <br /> 1190 • `let 14 Nd. /, /, Section s3 5" <br /> City,State / Zip Code Phone Number �p <br /> 4dw 1/1/4 t4N '^S '2- 651-'7�Q (/t:756— T 'II �(ctrcler <br /> N; Rt!bEor p <br /> II.Type of Building(check all that apply) +� <br /> 5i I or 2 Family Dwelling-Number of Bedrooms / Subdivision Namee CSM Number <br /> ❑Public/Commercial-Describe Use ThA,U5 c',(8 lE lr V1?w Park <br /> ❑State Owned-Describe Use ❑City_❑Village�ownship of 61.0'4, <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 <br /> B. ❑ Permit Renewal 0 Permit Revision ❑Change of 0 Permit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IV.Type of POWTS System: (Check all that apply) <br /> ❑Non-Pressurized In-Ground 0 Mound>24 in.of suitable soil 0 Mound<24 in.of suitable soil 0 At-Grade ❑Single Pass Sand Filter 0 <br /> Constructed Wetland 0 Pressurized In-Ground X.Holding Tank 0 Peat Filter 0 Aerobic Treatment Unit 0 Recirculating Sand Filter ❑ <br /> Recirculating Synthetic Media Filter ❑Leaching Chamber ❑Drip Line 0 Gravel-less Pipe 0 Other(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> VI.Tank Info I Capacity in Total Number Manufacturer Prefab Site Steel Fiber ' Plastic <br /> Gallons Gallons of Units Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks <br /> Septic or Holding Tank /3/7 <br /> 750 zos, Z {, e P 4,4�� <br /> Aerobic Treatment Unit 7 ✓ vJ vy�r y <br /> Dosing Chamber <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Pl�bcyr's Name(Print) / Plu ignat% MP/MPRS Number Business Phone Number <br /> , /o/ 1 <br /> 8c7/sy 7/5'-56' o762 <br /> Plumber's Address Street,City,State,Zipode) <br /> OR /c�yf,,i1 k /� L e/21lci- W j yk8 4 3 <br /> VIII.County/Department Use Only <br /> Approved 0 Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing Agent Signature(No S mps) <br /> Surcharge Fee) r b/ <br /> 0 Owner Given Reason for Denial 3�J' '24.I I q 144 <br /> 4.), <br /> IX.Conditions of Approval/Reasons for Disapproval .) 375Q> eAcit881547 <br /> APPROVED lEcEllvElo <br /> JUN 19 2019 <br /> Attach complete plans(to the County only)for the system on paper not less than 81/2 x 11 inches in size <br /> Burnett County <br /> Land Services Department <br /> SBD-6398 (R. 01/03) <br />