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%'• Industry Services Division County <br /> ``` B '\; 1400 E Washington Ave ,6V(NtT i- <br /> 1s1 Sp P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> : ., S I Madison,WI 53707-7162 5PJ- 2a- J LL .y/ <br /> .ft:s7s?j may' C✓1-. <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. <br /> I. Application Information—Please Print All Information <br /> Property Owner's Name Parcel# <br /> 'ViC4t` /1f4r7N o7-aa6-Z-3B-i7-Zb-6.-o -c -0/3000 <br /> Property Owner's Mailing Address/� 1 Property Location <br /> Z 3j LJ/ u N iLiti `k Pjl Govt.Lot <br /> City,State Zip Code Phone Number y... /.,, Z(� <br /> 1 j j , Section CJ <br /> 6 r �y rev r' 11872 crrcte oni� <br /> II.Type of Building(check all that apply) Lot# <br /> T N; R f E oE�/ <br /> I or 2 Family Dwelling-Number of Bedrooms Z Subdivision Name <br /> Block i <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number 0 Village of <br /> U Town of /P4.N/?/y <br /> Ill.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. �( <br /> V New System 0 Replacement System 0 Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> $ ge• 0 Permit Renewal 0 Permit Revision 0 Chan of Plumber 0 Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> Non-Pressurized In-Ground 0 Pressurized In-Ground 0 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 /> 3,00 . 1 yz 1 ti32 9yo '3 -7 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units ' ` c <br /> New Tanks Existing Tanks I t• U Ti y <br /> v u w <br /> i s C' 2 -E'' <br /> a :7 <br /> A-..U in v iL i7 a <br /> Septic or Holding Tank 766 750 / LJ ie e/ Y <br /> Dosing Chamber J�/ <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plun cr's Name(Print) Plumber's tore MP/MPRS Number Business Phone Number <br /> r T�lQ � �%� 86/96Z 7/1"- -O 2o-Z <br /> Plumhm's Address(Street,City,State,Zip Code) <br /> 6e'81 %vy-Af Z ie 4/ tiVe6 - L/ 5' q- <br /> VI1I.County/Department Use Only <br /> Approved ❑ Disapproved Permit Fee o Date Issued Iss - A ent ignature <br /> /16° 7/7/2)- �_ <br /> 0 Owner Given Reason for Denial WiNko,._. <br /> IX.Conditi ns of Approval/Rea o s for D sapproval t',�-.� j g i j �J�' E il <br /> al c - co.( Se- l�J l 11 v <br /> it-11 <br /> 00 JUL - 7 2022 i.:), <br /> Attach to complete plans for the system and submit to the County only on paper not less than 81 x It lrFhes in size <br /> Burnett County <br /> Land Services Department <br /> SBD-6398(R.08114) <br />