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'"°i` Industry Services Division County n <br /> X;' ® ;t,, 1400 E Washington Ave U( <br /> (s`.. S P P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> S : ., Madison,WI53707 7162 <br /> url�v , 3�-rL7 ( <br /> t, ---- rakK lesocK <br /> k.r4.uirtiv,. <br /> State Transaction Number <br /> Sanitary Permit ApplicationI <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),Stets. <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name /hr' <br /> / Parcel# <br /> Property Owner's Mailing Address Property Location i ib 1- <br /> 2 'OZ4 e)W 35— GovL Lot 13 D19 <br /> City,State Zip Code Phone Number .. k/ y, NV r, / <br /> J , Section <br /> OCAIPL w 5li 0 /' rcle one <br /> IJ T 7U N; R /c�ci E W <br /> II.Type of But ding(check all that apply) Lot# <br /> 1$I or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block R <br /> ❑Public/Commercial-Describe Use <br /> 0 City of <br /> ❑State Owned-Describe Use CSM Number 0 Village of <br /> 13 Town of Detg144 <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. 0 New System y 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 /> Qkon-Pressurized In-Ground 0 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.DispersaVTreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 100 ' 7 yz'I 1/7z el'30 <br /> VI.Tank Info I Capacity in ! Total #of Manufacturer <br /> Gallons Gallons Units a a o'a .2 <br /> New Tanks Existing Tanks c aU, -a "' y <br /> 2 p o S co <br /> c.V Oi ,n y rZv a- <br /> Septic or Holding Tank 7i1 75`O / L.A.e,C� <br /> Dosing Chamber J(/ Y. <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plu cr's Name(Print) i Plumber's Sigma MP/MPRS Nuepber Business Phone Number <br /> VIM.Ift r ,//' � 8 795'1/ 7/ ce.erz <br /> Plumhres Address(Street,City,State,Zip Code)/ <br /> 6 et 4 ' Ai Ile 4e tiveb4ei- LA- 5ife 93 <br /> VIII.County/Department Use Only <br /> 0 Approved 0 Disapproved Permit Fee� Date Issued Issuing ent Si <br /> 0 Owner Given Reason for Denial /7 5 5 f?' 03 94,,,.. <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> C9► ek- G.4 sib t Co /5kk .t'tn 11hs �7 �.. <br /> 0 -r I bow r, il @ eh of /l eu/d ,Se 3 ConCf� O 0 V 1 <br /> 50,ine is 5 7 i/ C4/1S,'5 Wl se),,l s�-. <br /> Attach to aumlete�far the system amd submit to the County only on paper not less than 8112 z I1 Inches's I`I N I 2 3 2023 <br /> ljj <br /> Burnett County <br /> _ Land Services Department <br /> SBD-6398(R.08/14) <br /> 515 c tck. 125 S <br />