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, ;z� �.ti - County <br /> 7 • „: Industry Services Division 15k-rrle'fl- <br /> 46,4 <br /> ;:iIP, ?1y4,.;.:';, 1400 E Washington Ave Sanitary Permit Number(to be tilled in by Co.) <br /> .. -` P.O. Box 7162 �!n Y _ �1 <br /> .,,; � �r„s. Madison, WI 53707-7162 (P 3 (o0 <br /> State Transaction Number <br /> Sanitary Pei m it 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 g3 ze 9 <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. <br /> I. Application Information-Please Print All Information Par(c St <br /> Property Owner's Name Parcel# <br /> /-b ti s11Ja✓iS6 v► 07- of 4-).-iio-/7-)S-B05:0m-G49,, <br /> Property Owner's Mailing Address Property Location <br /> D J o I at oo-'1 4v'e Govt.Lot I <br /> City,y,State Zip Code Phone Number / %, Section �s <br /> Crt T t1/4 r i Ca. PjT }/A O circle one} <br /> II.Type of Building(check all that apply) Lot# T `� N; R i E or IA/ <br /> 0 I or 2 Family Dwelling-Number of Bedrooms 3 3 Subdivision Name , <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSNI Number ❑ Village of <br /> ® Town of 14n 10'1 <br /> • <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ja4 New System <br /> y 0 Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. 0 Permit Renewal El Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV..;typeof POWTSSystem/Component/Device: (Check all that apply) <br /> Nt-Non Pressurized In-Ground 0 Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑ I{oldm=Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> VI Dispersll/Treatment Area Information: <br /> Des[gnFldw(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> 9c0 . 3' qoo 9 0 IA.o <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units a v a 7 c <br /> New Tanks Existing Tanks 9 o ei ga r <br /> a.U CI) . in w tJ a . <br /> Septic or Holding Tank /06 a /9 ® / �.1i iNroS igo/ >l <br /> Dosing Chamber- • - ) :,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 Signatur / MP/MPRS Number Business Phone Number <br /> i?I G lC /ley)iC 14 <br /> /n S f Lti�� ,4 JA 1S/ 7/S=8GG-e-P.S`7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> )77t(2, .33- 4-✓-eb-iv,, w ,11i Ir 7 <br /> VIII.County/Department Use Only <br /> grApproved ❑ Disapproved $ennit Fee Date Issued Is ins Age Signatur , / <br /> 0 Owner Given Reason for Denial 119'5 5/5/24 <br /> IX.Conditions of A� roval/Reasans for isapproval <br /> ECEDVE --- . <br /> ( 5e03,4 <br /> M �/� <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x I ®ch stze�/A/l 2022 /j <br /> Burnett County <br /> SBD-6393 (R0313) Land Servlcee Department <br />