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//'`'�'''"`� Industry Services Division County <br /> f f °�s\ <br /> ,r;, a L. 1400 E Washington Ave �urN f" <br /> tr -,.Spy -,+ P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) t/ <br /> �r ,.0 f /57-22--(`14.- <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(2),\Vis.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(I)(m),Slats.I. Application Information-Please Print All Information 271// 4, ievC! ,, ! <br /> Property Owner's Name Parcel# -Iduo 3 <br /> Tee dj ork/wel O7-04 a Y'i-17-65s1 o f-rx,a-o ricer <br /> Property Owner's Mailing Address Property Location <br /> /OZ 35- 0/.ti e/ Gout.Lot <br /> City,State ' Zip Code Phone Number �- <br /> 1 e <br /> W t / t r r' _ �+ %i Section <br /> 1 ] l/� S ��y, T 5N; R Ile our) <br /> apply)II.Type of Building(check all that a I Lot# E or <br /> a-I or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block* <br /> ❑Public/Commercial-Describe Use <br /> 0 City of <br /> ❑State Owned-Describe Use CSM Number 0 Village of <br /> Si Town of G.i).VCO1/`1 <br /> ill.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> ❑New System 4 Replacement System 0 Treatment/Holding Tank Replacement Only 0 Other Modification to ExistingSystem(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑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 /> 0 Non-Pressurized In-Ground 0 Pressurized In-Ground 0 At-Grade 0 Gound>24 in.of suitable soil TMound<24 in.of suitable soil <br /> ❑Holding Tank 0 Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> V.DispersaVTreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> Sav /.6) 0 d e 6 d 0 9Z 7 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units " <br /> New Tanks Existing Tanks -'a, U -�' <br /> L % <br /> y p �'. i 47 .G � ['S <br /> a U a K y in v a. <br /> Septic or Holding Tank / Z a e, <br /> Dosing Chamber 75- '/ /7k- / . X <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plu er's Name(Print) Plumber's Signs MP/MPRS Number Business Phone Number <br /> ati9 �114 � i85«5z; 7PT-s -626Z <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 6 S81 vo,- Ile ,/ (ilebcW-er v. 5'fb 3 <br /> VIII.County/Department Use Only <br /> ( Approved 0 Disapproved 5 �� Issued��� i Ag ,Si <br /> ❑Owner Given Reason for Denial (7'' 11 �- <br /> I rnett�ns�i'prov�aZons for Disapproval <br /> of <br /> r <br /> Attach to complete plans for the system and submit to the County only on paper not less than S la x I n sta <br /> bEP 1 3 2022 <br /> SBD-6398(IL 08114) Burnett County • <br /> Land Services Department <br />