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`^ Industry Services Division County .,, <br /> 1400 E Washington Ave 6,,,r,v(7474- <br /> ®s P = P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> = Madison,WI 53707-7162 5'11n1- -`74- Vr 13g ,-7 <br /> Sanitary Permit Application State ransaction 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 Services.Personal information you provide may be used for secondary zr,, l f.i/t <br /> purposes in accordance with the Privacy Law,s.15.04(1)(1n),Stats. a 1(a3 w✓r l�°f /z' f <br /> I. Application Information-Please Print All Information ��" r-fiff.f5.y vir <br /> Property Owner's Name Parcel# - 4 53 c, 01200 <br /> 16wy .0a41 berj <br /> (J 9c3/7; <br /> Property Owner's Mailing Address Property VonJ 1 ( i-1 v " Govt.Lot <br /> 2,0 <br /> City, <br /> State E 'r /� Zip Code Phone Number 5 id y, S�° br5 A AL V 556 e if <br /> !a. Section ' <br /> I <br /> (circle one <br /> II. a of Building(check all that apply) Lot# T �a N; R ' E or <br /> 141 1 or 2 Family Dwelling-Number of Bedrooms Y Subdivision Name <br /> / Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of ,,�j <br /> Town of ,/�r'✓"t 4,4 <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> ❑ New System Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. 0 Permit Renewal 0 Permit Revision 0 Change of PlumberList Previous Permit Number and Date Issued <br /> 0 Permit Transfer to New <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> .Non-Pressurized In-Ground ❑Pressurized In-Ground ❑ At-Grade ❑ 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 /> (0(0 . 7 �as9 7o 93 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units F o -0 u <br /> New Tanks ExistingTanks w o v u H N <br /> � � .o m m <br /> '�1 a a U vt to w 0 P. <br /> Septic or Holding Tank 100 <br /> 0 A *5° 114*I`t7 / �ef)er ), <br /> Dosing Chamber �yty <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumbe 's Signature MP/MPRS Number Business Phone Number <br /> �IIe 4. �1�---- lolls 7q s 7AP/6`/a0 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> I -?if 9?orl a (4r I ut.C/( k Lr 5` i5-3 <br /> VIII.County/Department Use Only <br /> pproved ❑Disapproved Permit Fee ex, Date Issued I 'n Age Signat,•/ f <br /> 0 Owner Given Reason for Denial $475 V////2") / <br /> IX.Conditions of Approv Res for Disapproval 3 7 �a4 a 5 L.I q <br /> M as S EVEOVE0 <br /> I -.-*15° 43047 <br /> Attach to complete plans for the system and submit to the County only on paper not less t t 11 frofyin9.6 2022 <br /> Burnett County <br /> Land Services Department <br /> SBD-6398 (R.08/14) <br />