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Industry Services Division County <br /> _ 1400 E Washington Ave �jf <br /> ® - P.O.Box 7162 <br /> S Sanitary Permit umberCire filled in by Co.)Madison,W153707-7162 / <br /> .l'rf� .GO ��(t37� <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 Services.Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# 07- --,2-qO-iy-.23-/ <br /> RU►%'-- i?1 d qlv_-1 or- tzn-ei/ <br /> Property Owner's n Mailing Property Location <br /> 293/f /loci‹e t1 Z,e. (W. Govt.Lot <br /> City,State Zip Code Phone Number 'A, 1/., Section ] <br /> rJ-/P..Oa e✓ J 1 i SL,i 24, (circle one) <br /> II.Type <br /> �o�f�Building g((check all that apply) (v Lot# T l��N; R 'ff E or� <br /> tl 1 or 2 Family Dwelling-Number of Bedrooms2 <br /> Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number 0 Village of <br /> rg Town of .60i�� <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> ❑New System �iReplacement System 0 Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal (❑Permit Revision ❑Change of Plumber 0 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 ❑Pressurized In-Ground ❑At-Grade 0 Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> Holding Tank ❑Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 3t, 11)k 11)i: 10A Nk <br /> VI.Tank Info Capacity in Total II of Manufacturer <br /> Gallons Gallons Units a 2 3 ,g <br /> New Tanks Fxiving Tanks Rq� y g r .. w <br /> t, j a.U rn so i%.CD n, <br /> Septic or Holding Tank /2S rj i�k 2u..v j X <br /> Dosing Chamber / �/��� <br /> 7.50 <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 /> AixfotA 10 icibel i C....___ s2o wri 7/5-/.oq -o7V*` <br /> Plumber's Address(Street,City,State,Zip C )n ` <br /> /3 7 Lcktx,�art t40 9/el/ , Cv s�g7/ <br /> VI County/Department Use Unly <br /> Approved ❑Disapproved Permit Fee Date Issued . g gent ignature <br /> 0 Owner Given Reason for Denial $3 75 1 1 121 Ida- <br /> DC Conditions of Approva easo s for Disapproval <br /> ►� u�e�- � Se4a + s .dz / Aeimerks <br /> D ECEIWE ---;) <br /> Attach to complete plans for the system and submit to the County only on paper not less than 31/2111 id,3 2 9 2022 i J <br /> Burnett County <br /> Land Services Department <br /> SBD-6398(R.08/14) <br />