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N <br /> �,,g it rr. County --,. <br /> g '`7,.= Industry Services Division /3 ta.►'✓f e 7 <br /> ,,-AfF` , P' 1400 E Washington Ave SanitaryPermit Number(to be tilled in by Co.) <br /> ' .. l'l <br /> _ 4 � - sx, P.O. Box N-Q3- a. <br /> '`' �> Madison,WI 53707-7162 I �-'68'( ; <br /> � _ y�,P� �o✓ %v <br /> �-ti 'lc�¢ai./ • <br /> S tate Transaction Number <br /> Sanitary Peimit Application <br /> • <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 PO4VTS 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 <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. <br /> /I. Application Information-Please Print MI Information sy 9 N For 9r i v-e <br /> Property Owner's Name Parcel# co <br /> a �oL.z-3�!8-CS=I -vJ�--o <br /> SG aft C (( v I7uoJt 1D: 332 7O -- d)//QO <br /> Property Owner's Mailing Address Property Location <br /> //XII? N , f le- dr ; ur Govt.Lot <br /> City,State Zip Code Phone Number % %, Section ,IS <br /> //''' �",� circle one) <br /> U1 av��f ��s J j y �L/1J T 32 N; R / Eor / <br /> II.Type of Building(che k all that apply) Lot# <br /> if 1 or 2 Family Dwelling—Number of Bedrooms 3 Subdivision Name <br /> Block# • <br /> ❑Public/Commercial-Describe Use • <br /> ❑ City of .. <br /> ❑State Owned—Describe Use CSM Number fl Village of e <br /> ❑Town of W©oca / w',- <br /> III.Type of Permit: (Check only one bor on.line A. Complete line B if applicable) <br /> A. ❑New System <br /> y 0 Replacement System 2'Treatment/Holding Tank Replacement Only 0 Other bloditication to Existing System(explain) <br /> • <br /> B. 0 Permit Renewal ❑Permit Revision • ❑Change of Plumber ❑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 /> ❑t.toa F essurized In-Ground ❑Pressurized In-Ground ❑ At Grade 0 Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> {o[am Tan ❑k I Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> V` Dispersal/Treatment Area Information: <br /> Design 'low(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(se Dispersal Area Proposed(st) System Elevation <br /> Ejs0 — — — <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units .n ? o 9 <br /> New Tanks Existing Tanks o u 2 a ca <br /> o.U m ti v-' u:to a. I <br /> Septic or Holding Tank d/ a 0 a ,4000 r-e°s-e✓ Y <br /> Dosing Chamber_ i .)I . <br /> ViI.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POINTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signatu e MP/MPRS Number Business Phone Number <br /> /Ziplc ® lc,) S 7 diA42 ,..;_, 6)S15I 7/5--F“- y/5-7 <br /> Plumber's Address(Street,City,State,Z ip Code) I <br /> ?7 . //tMy 3S' trv. 6S y..to. t:t/� ,S g 5 ? . <br /> VIII.CountylDepartment Use Only <br /> AiApproved ❑ Disapproved Permit Fee Date Issu d Issuino gent Signature _ <br /> ❑Owner Given Reason for Denial J l I�� ��Z�, 1 • <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> ha Q,U if s�cp S EEIVED <br /> retwr mAzyd-S ((Vv,' <br /> , LLow a.A CO(,tllf`1 I,r�,, - 73 t a.a <br /> ticid-iiny -kink mus-f- be vlctd O LUc ! 1 18 2023 <br /> tnd.eu -1-0 19-e v cl V—E—L CNYYi 1t. - Wua.Vi,uot ;to/ 2. 1 NOV <br /> Attach to t omplete plans for the system and submit to the County only an paper not less than 8 1/2 a 1l inches`in sail I - <br /> Burnett County <br /> Land Services Depart <br /> cron 42no ions,1\ <br />