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i!.};g,'a''t r;-`. County <br /> t :':=.• '`-:r4 Industry Services Division Sur ye I--1— <br /> j r ;£ •"' P': 1400 E Washington Ave Sanitary Permit Number(to be tilled in by Co.) <br /> P.O. Box 7162 ��,` _E� <br /> 4�, \;! xs./ Madison, WI 53707-7162 `�'/y 1 �� <br /> State Transaction Number <br /> Sanitary Peitnlit 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 <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Scats. 135 ZIP LAr'S0 Vl <br /> I. Application Information—Please Print All Information <br /> Property Owner's Name 1 Parcel# <br /> Ter'Ir'e>nce Mo./\ovle,/ o7.0 O-Z- 0-1y-I, 03-000-0I/000 <br /> Property Owner's Mailing Address Property Location - 7 1 ' 7 <br /> t 003-1 QJa.1,cr Lin Govt.Lot _ <br /> City,State 1 ` Zip Code Phone Number C� / �/, Section t t <br /> evic ple Grove IA 1\1' 553VI CO5I-26,9 - I319 circle one <br /> H.Type of Building(check all that apply) Lot# T 39 N; R �j E or W <br /> Kl or2 Family Dwelling—Number of Bedrooms Li Subdivision Name <br /> Block# <br /> ❑Public/Commercial—Describe Use <br /> ❑ City of <br /> ❑State Owned—Describe Use CSM Number ❑ Village of <br /> �Townof Web+ MavP51/1.1Ahd <br /> IIL Type of Permit: (Check only one box on line A. Complete line B if applicable) J <br /> A' 1New System <br /> y 0 Replacement System 0 Treatment/Holding Tank Replacement Only 0 Other N[oditication to Existing System(explain) <br /> B. 0 Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner - <br /> IV..Typeof POWTS.System/Component/Devi'ce: (Check all that apply) <br /> tglson Pressurized In-Ground 0 Pressurized In-Ground ❑ At-Grade 0 Mound>24 in.of suitable soil 0 Mound<24 in.of suitable soil <br /> ❑Ftoldm=Tank 0 Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> V Dispeirsnl/Treatment Area Information: <br /> Des Vac*(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> Coon .-7 ZSS7 9 o 0 9 I , o' <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o 7 5 <br /> New Tanks Existing Tanks 2 ;; v o <br /> VgI <br /> 0 <br /> c,U cn v, cn cc-C7 a. <br /> Septic or Holding Tank 1 — MSc 1 I,v L e 5e r" 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 Signature MP/MPRS Number Business Phone Number <br /> -R iclAcke A. Po?kil4S /Gam- ^1/ / 21.5 I 75-Oslo(o-Li 157 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> • <br /> 2'7-M20 14LA-)Y 3s- uie +eir- . uJI 5 3 . <br /> VIII.County/Department Use Only <br /> Permit Fee 00 Date Issued Issuing Age Signatur <br /> ®Approved ❑ Disapproved <br /> ❑Owner Given Reason for Denial PI (`{�IX.Conditions of Approval/Re sons f r Disapproval , t ' �{ 4- S <br /> �ee4- Ace 54 <br /> IDIECEOVEI <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 1l inche si i� C t 1 022 „ <br /> SBD-6398 (R0313) Burnett County —J <br /> Land Services Department <br />