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N <br /> ,,_'g..a-''j3. County <br /> 1: -i` Industry Services Division ei"',I'e ~ <br /> ik f i , ' = 1400 E Washington Ave Sanitary Permit Number(to be tilled in by Co.) <br /> .,.. - 3 <br /> 0!'` r1 P.O. Box 7162 <br /> -a, ! ;..: .r;,, Madison, WI 53707-7162 Q��g <br /> ti.. st.Fy.,`� {�1�f <br /> State Transa tLon/Nlumber' <br /> Sanitary Pei mit 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 _PO <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. V t )� A <br /> r e Pp {✓ <br /> I. Application Information-Please Print All Information G� <br /> Property Owner's Name Parcel# <br /> /� v7-olJ-a-`�o-lS--d9-,�-05-- 007 <br /> Ud reeve /3/4nLIt4ral - U//vOp <br /> Property <br /> Owner's Mailing Address ,�1 Property Location <br /> ) 3) 3 13/OOen cLc1 st /'�I'e Govt.Lot Ca 7 <br /> City,State Zip Code Phone Number /, 'A,, Section A <br /> (.till; -f-e ./ rA - i/r G /l/ S 5 7/(, Lu•cle one) <br /> IL Type of Building(check all that apply) Lot# T y� N; R tS E ore) <br /> l or 2 Family Dwelling-Number of Bedrooms 3 I Subdivision Name <br /> Block# <br /> 0 Public/Commercial-Describe Use ❑ City of <br /> ❑State Owned-Describe Use CSNI Number ❑ Village of(/', -1 P. ,/ J <br /> ja Town of 4 G/45 k l <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> ❑ New System RTReplacement System 0 Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> B• ❑ Permit Renewal ❑Permit Revision ❑ Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner - <br /> IV..:Cypeof POWTS,System/Component/Device: (Check all that apply) <br /> Non 0.g_i urized In-Ground 0 Pressurized In-Ground 0 At Grade ❑ Mound>24 in.of suitable soil 0 Mound<24 in.of suitable soil <br /> ❑ I{olan3 Tank 0 Other Dispersal Component(explain)) 0 Pretreatment Device(explain) <br /> V..Dispersal/Treatment Area Information: ,,, <br /> DesigrTIow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> 11,37 . -7 GN3 (s`v 91. 4/ ei 70l 9 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units �, o '= <br /> New Tanks Existing Tanks o u i 5 <br /> n.U En h rn u-U o <br /> Septic or Holding Tank 0 (v <br /> / 0 /6,60 / ..fin/`.` /fr,-aili✓ //` <br /> Dosing Chamber_ ) . <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// ,.�7 <br /> `C /G/G JIG IG/in S 72e1/ /�Y//O - O]0t,5 _S`/ 7/.f Y.. 6- 7/✓ <br /> Plumber's Address(Street/City,State,Zip Code) <br /> 01776 0 7/H,� 7S` 1/-e6 s>zCr wr cit't rc i <br /> VIII.County/Department Use Only _ <br /> Approved ❑ Disapproved Permit Fee C� Date Issued Issuin�o ent ign e _. <br /> 0 Owner Given Reason for Denial $ a" "8I 2.? <br /> I;.Condit-Ions of Approval/Reasons for Disapproval `gyp <br /> 1441-5 <br /> D _ <br /> MAY 0 3 2023 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 l/2 x It inchts in size Burnett County <br /> (�La fi <br /> Land- Services Department <br /> SBD-6398 (R0313) -`�' / 406 <br />