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-e....;-r',z,7r=;;:, County <br /> 1=. -• ' „+ Industry Services Division Bo ry�-1-'1-- <br /> ,,.cr A; ., 1400 E Washington Ave <br /> ;�t 2.:•�t;�;:,:: ;, 9 Sanitary Permit Number(to be tilled in by Co.) <br /> .;; 40,: it PI P.O. Box 7162 r' C� /-i1 <br /> '''• ' .s `• � Madison, WI 53707-7162 J a �u �`L3y�/ <br /> r <br /> State Transaction Number <br /> Sanitary Permit Application <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 LK <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. Z(#�!SLl N.14 UPS Rd_ <br /> I. Application Information-Please Print All Information 5F os ( W= 5ij1 o I <br /> Property Owner's Name Parcel# <br /> Ltncolrt 8u1- ke -hi- a7•oaq-z-31-1'i-iz•z vz-000-01,3ooa <br /> Property /�Owner's <br /> . /'l Mailing Address Property Location <br /> 215�-l9 Co R Govt.Lot <br /> City,State Zip Code Phone Number / %, Section 2 <br /> Zeal-903-vo (circle on <br /> �J�UVItV' WI Sy`dd l T 39 N; R {Y E or <br /> IL Type of Building(check all that apply) Lot# <br /> KI or2 Family Dwelling-Number of Bedrooms 2- Subdivision Name <br /> Block# • <br /> 0 Public/Commercial-Describe Use <br /> ❑ City of <br /> CSM Number 0 Village of <br /> ❑State Owned-Describe Use t_o+2 CSAV 0 X Town of IZvSK <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. to <br /> 1,8,New System <br /> y 0 Replacement System 0 Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> - <br /> B. 0 Permit Renewal CIPermit 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 /> Non Pressurized In-Ground 0 Pressurized In-Ground ❑ At Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑ E{dldmiTank ❑Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> V Dispers.'al/Treatment Area Information: <br /> Desi0Tl6ry(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> Soo • 7 W29 LI37z,. _ 9).4 4--9Z.0O <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units JO a)v o <br /> New Tanks Existing Tanks o v V g c"a c"a <br /> , , t ao cn w cn wQ a. . <br /> Septic or Holding Tank 1 so 750 l U-1 i e'Se.r 1 <br /> Dosing Chamber_ ) -) <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POINTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature NIP/MPRS Number Business Phone Number <br /> ZC.Lo r d 14 opk l HS /—Z.4..J /4 , • <br /> ., 2z58si 715-`6/(o-14157 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> ZT7100 I4wy 35 web5+er LOX 5 fctA <br /> VIII.County/Department Use Only <br /> Approved ❑ Disapproved Permit Fee 00 Date Issued Is in Age t Signa e <br /> Astt u . <br /> ❑ Owner Given Reason for Denial $ 1�Z� Li WI a� . : , /,; r <br /> IX.Conditions of Approval/Reasons for Disapproval , E C IE n �/J ('�-� <br /> 0 �eeA- G U 5 D CI<#07 G 99 �C fl <br /> APR 2 1 2022 Lzy <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 I/2 s 11 inc'es in size`. j <br /> Burnett County <br /> Land Services Department <br /> SBD-6393(R0313) <br />