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�� �_.,r, .\ IndustryServices Division <br /> i - County Af ve <br /> 0 ~1' 1400E Washington Ave <br /> 1;1 S 17: P.O.Box 7162 <br /> SE Sanitary Permit Number(to be filled in by Co.) <br /> \ Madison,W1 s370'i 7162 • ,a N- �-l5t`o �, b$q� <br /> �. , c9T-22- 5 <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. �� aI. Application Information-Please Print All Information <br /> CO <br /> Property Owner's Name Parcel# j- 3 V b6 <br /> I A7,-/ ov 5 07-03i z y0•/7-/y'S Oz-000-oi1tCO <br /> Property Owner's Mailing Address Property Location <br /> 30272 ,( y <br /> ` e Govt.Lot <br /> City,State Zip Code Phone Number ��! <br /> �" '''4 'A, Section <br /> ,da/ 1 t,ft t 514,3a acircle one <br /> II.Type of Building(check all that apply) Lot# T N; R /Sf E�� <br /> I or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block Al <br /> ❑Public/Commercial-Describe Use <br /> 0 City of <br /> ❑State Owned-Describe Use CSM Number 0 Village of <br /> ®Town of ON(ONl <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. �y <br /> L7 New System 0 Replacement System 0 Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> B• 0 Permit Renewal 0 Permit Revision 0 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 /> Cd Non-Pressurized In-Ground ❑Pressurized In-Ground 0 At-Grade 0 Mound>24 in.of suitable soil 0 Mound<24 in.of suitable soil <br /> ❑ Holding Tank 0 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 /> 95o . 1 695 ye() 9'32/ <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o y <br /> New Tanks Existing Tanks U '' y <br /> U <br /> O v .a t7 <br /> a.U in :: rn tL v a <br /> Septic or Holding Tank (VfJ//S,I O /c2 1 ('}I e,e c- <br /> Dosing Chamber v <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Nun cr's Name(Print) Plumber's Sign MP/1b1PRS Number Business Phone Number <br /> Plumh�r s Address(Street,City,State,Zip Code) <br /> S 6� zoo <br /> 6e8/ ,vM iv l le 41 (ikJeb - LA- 51'59 3 <br /> VIII.County/Department Use Only <br /> 4 Approved 0 Disapproved Permit Fee cc" Date Issued� Issuiyn Ag t Signs <br /> 0 Owner Given Reason for Denial S375' 7 1 ( (/2? C yC.•�1" <br /> • <br /> IX.Conditions of Ap roval/R"e�assoons for Disapproval <br /> 0Y1 .e -- ,iI 5�t 4C(f— - 64,4 4235--- $-37s <br /> Th <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 la a 11 inel aett4 <br /> ilk - d 2022 Ji <br /> - .. _/ <br /> SBD-6398(R.08/14) Burnett County <br /> Land Services Department <br />