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N <br /> /:,.-';./ rjv• <br /> • County � <br /> f �` Industry Services Division B <br /> arn�e <br /> ,4 A • 1400 E Washington Ave Sanitary Permit Number(to be tilled in by 1 P.O. Box 7162 <br /> SAtJ-at-2gy GNo Co.62� <br /> '4� _... -r'x! Madison, WI 53707-7162 <br /> Crs a( 2,s <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 goverwnental 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 A 75-5- 3 3tAScl <br /> purposes in accordance with the Privacy Law,s.15.04(I)(m),Stats. <br /> I. Application Information—Please Print All Information 74 0..a,a$oh Rol <br /> Property Owner's Name Parcel# O e <br /> 7-3 sii reav1cis Not Installed e7-a,d-a. ye-IS--36-✓ �" <br /> cui.Too <br /> Property Owner's Mailing Address Property Location <br /> dl5).1 Redw,v7 flue <br /> Govt.Lot <br /> City,State Zip Code Phone Number <br /> _ ,A,, 'A,, Section 36 <br /> Jbr M N 014.11 6S 5-of (circle <br /> T 4/0 N; R /.s` e one) <br /> U.Type of Building(check all that apply) Lot# <br /> Dl:1 or2 Family Dwelling—Number of Bedrooms 3 .2 Subdivision Name , <br /> Block# <br /> 0 Public/Commercial—Describe Use • <br /> ❑ City of <br /> ❑State Owned—Describe Use CSM Number ❑ Village of <br /> Iff Town of J.Gt'So,1 <br /> Ili.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> 0 New System Cif Replacement System ❑Treatment/Holding Tank Replacement Only 0 Other Ivloditication to Existing System(explain) <br /> B. ❑ Permit Renewal ❑Permit Revision ❑Chancre of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTSSystem/Component/Device: (Check all that apply) <br /> V`Non Pressurized In-Ground 0 Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑ Haldma Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V;Dispers'tl/Treatment Area Information: ' <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required Of) Dispersal Area Proposed(st) System Elevation <br /> tiro . 5" - 900 clo0 93. 7 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units a -o 0 <br /> New Tanks Existing Tanks w c U c`� , `^ <br /> a U m' y vo u-U a. <br /> Septic or Holding Tank <br /> /6” /000 / P-t t°,S',;Y x <br /> Dosing Chamber.. GOO Gov 1' I---- <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWfS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Si tare MP/MPRS Number Business Phone Number <br /> )214./c Nmpk,ft f / ii/ av,s'es-7 -71.f.-g 6- G//s- <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 7.7 D / .ZS AAe6. 0r✓ Gv <br /> VIII.County/Department Use Only <br /> Permit Fee Date Issued I en gna <br /> 0 Approved ❑ Disapproved <br /> ❑ Owner Given Reason for Denial <br /> as CI h 21 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> SEP 14 2021 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 In,.rl l es in size <br /> Burnett County <br /> SBD-6398(R0313) Land Services Department <br /> A l/i.1- ... • 1 C•cs 4 l/ .f% <br />