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', " ..- County -,i <br /> ' ` .NZI , Industry Services Division L5LA✓'i-eo/�1 <br /> :?if :•yt:c,.;.: „-P'. 1400 E Washington Ave Sanitary Permit Number(to be tilled in by Co.) <br /> t P.O. Box 7162 <br /> `:::: -i <br /> V,p,t. rs, Madison, WI 53707-7162 <br /> 1 CS1'--22-- l 83 'E'� j <br /> State Transaction Number <br /> Sanitary Pet nu t 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 oi 26 a7 <br /> purposes in accordance with the Privacy Law,s.15.04(l)(m),Stats. <br /> I. Application Information-Please Print All Information . /k I15 A/- <br /> Property Owner's Name Parcel# <br /> T/hl /ld" /✓lg ` G L/l660 <br /> Property Owner's Mailing Address Property Location ' <br /> Pa BOX -5-- Govt.Lot <br /> City,State Zip Code Phone Number /, %, Section d <br /> /) 4 b., yD c cle one <br /> II. Type Building(check alla apply) Lot <br /> Lot# T N; P. / E o� <br /> I or 2 Family Dwelling-Number of Bedrooms 2 Subdivision Name <br /> Block# <br /> 0 Public/Conunercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number p Village of <br /> Town of 3AGg-Ca h <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. )(New System 0 Replacement System 0 Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> B. 0 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 POWTSSystem/Component/Device: (Check all that apply) <br /> Non Presa razed In-Ground 0 Pressurized In-Ground ❑ At Grade 0 Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑YFlgldma Tank 0 Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> V..Dspersal/Treatment Area Information: <br /> Design ldw(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> /.70 _ . 7 ii--- 4410 5 `-/ <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o 0 o <br /> New Tanks Existing Tanks o v a . T <br /> a U cn v, i u CD a. <br /> Septic or Holding Tank 3OB) O a / h 1 z f r - )e' <br /> Dosing Chamber- — <br /> J i : t <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 Signature MP/MPRS Number Business Phone Number <br /> l' r -./ //U /i k-, s / ��,,4' ,t s7s// Nil-go a—y/5-7- <br /> Plumber's Address(Sttet,City,State,Zip Code) <br /> )776a 'L 7 3.$ w -6L/ram tA- S t5J' . <br /> VIII.Countv/Department Use Only <br /> Approved 0 Disapproved Permit Fee Date Issued ing ent Si, <br /> Njif0 Owner Given Reason for Denial $375 1013!a? <br /> IX.Conditions of Approval/Reaso b for tsapproval ^ a <br /> inee4- ail Seri- aC. <br /> 7)17h <br /> 2022 _ji <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 '_x 1 ches in size Q 7f <br /> Burnett County <br /> Land Services Department <br /> SBD-6393 (R0313) <br />