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N <br /> i., ;, . *.� - County <br /> M% '``"r4 Industry Services Division /3u.y'yt eft <br /> ;mot= ? :.:':` , e" 1400 E Washington Ave Sanity Permit Number it ;;ti;,S :,,•,; Sanitary (to be tilled in by Co) <br /> a .t P.O. Box 7162 � �+ 103 r l <br /> 4, r Madison, WI 53 70 7-71 62 <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 30 /33- <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. <br /> I. Application Information-Please Print All Information Pr)I viet/et ?of <br /> Property Owner's Name Parcel# <br /> �IcLla�m1 .�417•�Sen o7-o3A-d-1Il-/6-'17-3 °a -aeo <br /> 0l/d oe <br /> • <br /> Property Owner's Mailing Address Property Location <br /> a.9'(pSI R e1 ©a ic Or Govt.Lot <br /> City,State Zip Code Phone Number y, %, Section A 7 <br /> Day)Oury ' t"1 tr3 0 (circle one) <br /> II.Type of Building(check all that apply) 1 Lot# T N; R �� E or� <br /> Vi 1 or2 Family Dwelling-Number of Bedrooms �+ Subdivision Name • , <br /> Block# <br /> 0 Public/Commercial-Describe Use ❑ City of <br /> ❑State Owned-Describe Use CSM Number 4 9 0 Village of <br /> V. �3 t 0 Toavnof - 1.^1/If <br /> 39 irSob _ <br /> IIL Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> A New System 0 Replacement System 0 Treatment/Holding Tank Replacement Only 0 Other Moditication to Existing System(explain) <br /> B• ❑ Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration r Owner <br /> IV.Type of POWTS System/Component/Device (Check all that apply) <br /> ❑-Non Press ized In-Ground ❑ Pressurized in-Ground ❑ At Grade ❑ Mound>24 in.of suitable soil 0 Mound<24 in.of suitable soil <br /> Ffoldmg Tank ❑Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> V�Dspersal/Treatment Area Information: <br /> Desi Fld*(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(st) I Dispersal Area Proposed(st)1 System Elevation <br /> 36 0 — -- <br /> VI.Tank Info Capacity in Total #of Manufacturer v <br /> Gallons Gallons Units a B <br /> i y <br /> New Tanks Existing Tanks 9 o u di m <br /> • au v, ti yr cz.0 F. <br /> Septic or Holding Tank AlS0/71-0 440/10 / tA/ r .r er J`C J <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 Si ature MP/MPRS Number Business Phone Number <br /> /Z/C f f,/o/p/e/h.3 /2��c Si <br /> f/ dir8.s-1 7/57 EGG- 1I/S 7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> ). 7..7 o , , 3. - /i2.4.•6..s-ir. w7" s.5,,er 3 <br /> VIII.County/Department Use Only <br /> pproved 0 Disapproved Permit Fee Date Issued is ug Ant Si, <br /> 0 Owner Given Reason for Denial $375 5 J3l lea _ <br /> DC Conditions of Approval/Reasons r Disapproval © <br /> D JE C <br /> (rice+ 411 56-thl ---- .r..) <br /> 50:1 re tie t y -e w :5 Oel/n - -4 Ile '11(,3� <br /> �a" w ,/y L-. I —o% MAY 2 7 2022 <br /> Attach to complete plats for the system and submit to the County only on paper not less than 8 1/2 a 11'riche t in size 1 <br /> Burnett County 1 <br /> Land Services Department <br /> SBD-6398 (R0313) <br />