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County <br /> i:f:�.,:, �r4 Industry Services Division <br /> :. ft. 1400 E Washington Ave Sanitary Permit Number(to be tilled in by Co.) <br /> .. ., ;i'.,,� .: 5; P.O. Box 7162 <br /> * ,. s't,=:,s =_,i Madison, WI 53707-7162 <br /> ' o'S 473/ si7`t <br /> z �i <br /> State Transaction Number <br /> Sanitary Petmit Application <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 Servies. Personal information you provide may be used for secondary 6 ey i / /�� <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. M t n r;;1"✓!. n 6�t►1y <br /> I. Application Information—Please Print All Information Parcel# <br /> Property Owner's Name S"os-o0`' 0170619 <br /> /ewe p.....dliy <br /> Property Owner's Mailing Address Property Location <br /> 6 I 43eya.ot LA Govt.Lot <br /> City,State Zip Code Phone Number y, y, Section 35 <br /> (circle one) <br /> �Nv'Nf ViiIe M� ,5-5337 T y/ N; R / Eor® <br /> II.Type of Building(check all that apply) Lot# <br /> V I or 2 Family Dwelling—Number of Bedrooms <br /> 3 Subdivision Name <br /> Block# . <br /> ❑Public/Commercial-Describe Use ❑ City of <br /> CSM Number ❑ Village of _ <br /> ❑State Owned—Describe Use X Town of f w 11.5 <br /> III.Type of Permit: (Check Only one box on line A. Complete line B if applicable) <br /> A' ❑ New System Y Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> List Previous Permit Number and Date Issued <br /> B. ❑ Permit Renewal ❑Permit Revision ❑ Change of Plumber ❑Permit Transfer to New <br /> Before Expiration Owner <br /> IV. Type of POWTS,System/Component/Device: (Check all that apply) <br /> Nbn P essuriaed In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Ivlound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑-holding Tank ❑Other Dispersal Component(explain) ❑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(st) System Elevation <br /> 115-0 _ -7 6 e/3 6.s`o 93. 0 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units ° y cci <br /> New Tanks Existing Tanks E o — 01 H <br /> c U v, ti cn iE ci a- <br /> Septic or Holding Tank /1 o G o /04 j J ZN f"� t o e,..to , X <br /> Dosing Chamber- i <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POINTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> /2/G/e /Ay 1(1 Ai /"Z'// % '/ -74r=g6-4,/.3'- <br /> Plumber's Address(Street,City,State,Zip Code) <br /> of77ke A114# 3S Lri A.C71'r*' LyL 5p . <br /> VIII.County/Department Use Only <br /> Permit Fee Date Issued Issuing Agent Signature _ <br /> Npproved ❑ Disapproved / G v'Cirww�/ <br /> CI Owner Given Reason for Denial $ 7'S /�J. 0 G •2. I �.v ` <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> D <br /> RICIEDVIE '-1\ . <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 uz x 1a in sin size <br /> J <br /> Burnett County <br /> Land Services Department <br /> SRD-F3ne(izn3l 1) <br />