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---^!,.t <br /> f^:� �`\ Industry Services Division County <br /> 47, D ;c 1400 E Washington Ave & Nei <br /> Isl - $ P.O.Box 7162 <br /> ,, $ Sanitary Permit Number(to be filled in by Co.) <br /> - Madison,WI 53707-7162 j/1f( .-,. 2-j (, (p43 3 <br /> ::,,,..,... CFI; ='^ _ 7 <br /> Sanitary Peu nit Application State Transaction Number <br /> In accordance with SPS 383.21(2),1Vis.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),Slats. � �A�G�4� �� n/ <br /> I. Application Information—Please Print All Information 66 2 I/e{//� <br /> Property Owner's Name Parcel# <br /> _ C1 ft, 1AJ a 5 key o vise-z- 0 -o3-5- i6--zal-o40,0 <br /> Property Owner's Mailing Address Property Location <br /> Z,595. ' qId C £/ - <br /> Govt.Lot <br /> City,Staten Zip Code Phone Number %. 3 <br /> Ave , 'A, Section <br /> er ei n C ircle on <br /> II.Type o Building(check all that apply) Lot 4 T �� N; R �� E o Vr <br /> ifI or 2 Family Dwelling—Number of Bedrooms / Subdivision Name <br /> Block R <br /> ❑Public/Commercial—Describe Use <br /> 0 City of <br /> ❑State Owned—Describe Use CS\1 Number 0 Village of <br /> 'Town of O44k4 iJ <br /> Ill.Type of Permit: (Check only one box on line A. Complete line B if applicable) • <br /> A. <br /> CYNew System 0 Replacement System 0 Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> B. 0 Permit Renewal ❑ 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 /> 1 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(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> D .1 IV 157 9?3 <br /> VI.Tank Info Capacity in Total m of Manufacturer <br /> Gallons Gallons Units o • <br /> New Tanks Existing Tanks g h <br /> m U <br /> .,c. U U <br /> a .- E Z :0 <br /> a U %n v to ii: v a. <br /> Septic or Holding Tank /210 /250 / e�r <br /> Dosing Chamber �/ - �� <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for Installation of the POWTS shown on the attached plans. <br /> Plun er's Name(Print) / Plumber's • mireMPIMPRS Number Business Phone Number <br /> Or* /o��� /�G✓�1 8 /9 7! --� - <br /> azdz <br /> Plumh,tr s Address(Street,City,State,Zip Code) <br /> 6S8f % tIc Ai tje6 7 LI.' 5'f 93 <br /> VIII.County/Department Use Only <br /> ZiApproved 0 Disapproved Permit Fee Date Issued in Ag nt Sigma e <br /> 0 Owner Given Reason for Denial S 1.15— 'I I?aI ag- � <br /> IX. onditions of Approval/Reasqns Nsapproval <br /> (hee-I- all JC��.rj(I,'Jj{U� <br /> -4.-r----. %--t- E 0 v E \ <br /> i <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 l2 s I II es ize A}�R 2 1 201� <br /> IL <br /> ( « b --Burnett County <br /> SBD-6398(R.08114) Land Services Department . <br />