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''"'Dii-\ Industry Services Division County <br /> ;i-�r ~� `• 1400 E Washington Ave grai6ir <br /> pi Sp P.O.Box 7162 Sanitary Permit Number(to be filled in byCo.) <br /> S .' Madison,WI 53707-7162 gAxi 02 2..j 2 643 N 05 <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 Services.Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. )? 13' .544Mcive1411 <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# 40 35.167 <br /> ieket i'cue4&,..uer oxaac14 7-ZY- '61,00a'olitoo <br /> Property Owner's Mailing Address C � Property Location <br /> 7VIP/ iikikiet(/�A 4/ Govt.Lot <br /> City,State Zip Code Phone Number , y/ Z 9 <br /> p� 1V /�, /,, Section <br /> 6••re.J �'' SJ�(/72 rcle one, <br /> T '�y N; R I E o 1rV <br /> II.Type of Building(check all that apply) Lot# <br /> ri'1 or 2 Family Dwelling-Number of Bedrooms if Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use 0 City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of /� <br /> Ei Town of llt�m.C'.5 <br /> Ill.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> (li New System 0 Replacement System 0 Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> B. 0 ❑Chan a of PlumberList Previous Permit Number and Date Issued <br /> Permit Renewal 0 Permit Revision g 0 Permit Transfer to New <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> Pt Non-Pressurized In-Ground 0 Pressurized In-Ground 0 At-Grade 0 Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑ Holding Tank 0 Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> V.Dispersav Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units r., o <br /> New Tanks Existing Tanks . <br /> U d WI N 2 <br /> O 2E u .G a CJ <br /> c.V iii Tn. rn ii: v E. <br /> Septic or Holding Tank lojiple, a SO act) I ��•/f r,4u <br /> Dosing Chamber "V <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plu cr's Name(Print) Plumber's lure MP/MPRS Number Business Phone Number <br /> cpt <br /> Plump'-r's Address(Street,City,State,Zip Code) <br /> 6581 %Wi w t le ,/ tJebi-er- v. 5i/69 3 <br /> VIII.County/Department Use Only <br /> Approved ❑Disapproved Permiti Fee O Date Issued Issuing A nt Si e <br /> 0 Owner Given Reason for Denial S li O 5 2`l 1 o/P-a C <br /> IX.Conditions of Approval/Reasons for ntcnnprnval <br /> Elfg.q <br /> ' 1101 <br /> FF RR4 202"1Attach to complete plauc for the s}'stem gad suhmit to the Counts only on paper not less thatilia size• <br /> Burnett County <br /> Land Services Department <br /> SBD-6398(R.08/14) (a. C.,S <br />