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y_',gsi idi:r;.� County <br /> 7 .; '`Vr4 Industry Services Division 8KYhe/ <br /> r A` ., 1400 E Washington Ave <br /> ':�r `?�'�'' -� �� 9 Sanitary Permit Number(to be tilled in by Co.) <br /> P.O. Box 7162 3 Ant 2 7 S <br /> . ✓,s. Madison, WI 53707-7162 4.4 314 C.F <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with BPS 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 POWVTS 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 y34 0 <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. /11 a iturd Lie fop( <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> 07-oIJ.4-40-1S-341—S0S=0(4-0.13000 <br /> Property Owner's Mailing Address / Property Location <br /> /,?7X/a,sA droa 41vv.$. Ldt ',13 Govt.Lot ) <br /> City,State Zip Code Phone Number / % Section y <br /> .S . /7,0-5 ct d eln A. F/ 31707-3 7J1a cmcle one) <br /> T �f� N; R /� E ox' <br /> II.Type of Building(check all that apply) Lot# <br /> g I or2 Family Dwelling-Number of Bedrooms (i _/ Subdivision Name , <br /> Block# <br /> 0 Public/Corrunercial-Describe Use ❑ City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of <br /> ® Town of .�o.c 14S6.7 <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. 1-1 <br /> ❑ New System Replacement System ❑Treatment/Holding Tank Replacement Only 0 Other Nloditication to Existing System(explain) <br /> B. ❑ Permit Renewal ❑Permit Revision List Previous Permit Number and Date Issued <br /> ❑Change of Plumber ❑Permit Transfer to New <br /> Before Expiration Owner - <br /> IV.Typeof POWTS.System/Component/Device: (Check all that apply) <br /> ,Non 1 t i iinzed In-Ground 0 Pressurized in-Ground ❑ At Grade ❑ Mound>24 im of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑•FfoldmgTank 0 Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Des ign-F16 i(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(st) Dispersal Area Proposed(st) System Elevation <br /> 'GO :7 /,I8s' 1)16 91'-5" <br /> VI.Tank Info Capacity in Total #of Manufacturer , <br /> Gallons Gallons Units 13 t) o 4, o <br /> WI <br /> New Tanks Existing Tanks ^ � o v 6 di d <br /> M c,U cnn ,,, vs u.C7 a <br /> Septic or Holding Tank / <br /> Dosing Chamber- /7,ce' --Sj 75 • ,.ors-e / 1 3t <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'ss Signature MP/MPRS Number Business Phone Number <br /> kfe. k i h f )7,,t, 4,-, /at r//� GUSTY 1 70-3.a‘----qA77 <br /> Plumber's Address Street,City,State,Zip Code) <br /> i ?760 buy 35-Gi/Gdslr., L��.-S`-r 55' <br /> VIII.County/Department Use Only <br /> Approved 0 Disapproved /-Fe Pencil Fe�e Date Issued Issuing Age Signa <br /> 0 Owner Given Reason for Denial S 5/l//32 <br /> • <br /> IX.Conditions of A proval/R aso for Disapproval <br /> ine&V. CO Se-� C C� C II M G �1 <br /> ion sekb�U -10 skc� of sked netts -+D be mop _ ,. <br /> Pi P i l n aes -iv be s ; e MAY 10 21121 <br /> Attach to complete plans f�or the system and submit to the County only on paper not less than 8 1/7.s 11 inc 1 in e <br /> Burnett County <br /> SBD-6398 (R0313) Land Services Department <br />