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/r - Coun <br /> ii< 4 � Industry Services Division ty Burnett <br /> its `. 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> P.O. Box 7162 <br /> v�L = z Madison,WI 53707-7162 0�� as aU /' <br /> iii , L Q LI L I c-„ - - O <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 Servies. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. 28914 Brozie Rd. <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> Tasha Stillman 028410903812 <br /> Property Owner's Mailing Address Property Location <br /> 4104 145th St. E Govt.Lot <br /> City,State Zip Code Phone Number '/, SW '/, Section 9 <br /> Tacoma WA 98446 (circle one) <br /> II. 6e of Building(check all that apply) Lot# T 40 N; R 14 E or W <br /> 1 or 2 Family Dwelling-Number of Bedrooms 2 3 Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number 0 Village of <br /> 3832 of Scott <br /> III.Type of ermit: (Check only one box on line A. Complete line B if applicable) <br /> A. New System <br /> y 0 Replacement System 0 Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal 0 Permit Revision 0 Change of Plumber 0 Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.hype of POWTS System/Component/Device: (Check all that apply) <br /> Non-Pressurized In-Ground 0 Pressurized In-Ground ❑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 /> 300 .5 600 600 95.0 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units .a 2 o 2 <br /> New Tanks Existing Tanks g 2 1 id M <br /> au .FA vi X.C7 n. <br /> Septic or Holding Tank 750 77 evrr 1 ( i!' -5—p— X <br /> Dosing Chamber <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's S. a MP/MPRS Number Business Phone Number <br /> Rick Brown d 231251 419-0739 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO Box 637 Spooner WI 54801 <br /> VIII.County/Department Use Only <br /> l pproved CI Disapproved Pe it Fee p Date <br /> Issued Is in A•gg t Si e <br /> 0 Owner Given Reason for Denial $ 1;la. <br /> 5 q J 111/ C ��IK�( <br /> IX.Conditions of Approve ia <br /> asons or Disapproval <br /> el( <br /> 1:1 ,., <br /> Attach to complete plans for the system and submit to the County only on paper not less than 81/2 x 11 , -. Sze . „ „ . . <br /> O ^0^2 <br /> JO <br /> SBD-6398(R0313) I <br /> Burnett County <br /> Land Services Department <br />