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44. s,�s Industry Services Division County <br /> 4r,: Y TD ;4. 1400 E Washington Ave v/�/e# <br /> (}i:. ; P.O.Box 70 <br /> �� !� ;; Madison,WI 53707-7162 Sanitary Number(to be filled in by Co.) <br /> A. <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this foam so 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 infosmation you provide maybe used for secondary <br /> purposes in accordance with the Privacy WILL 15.04(1)(m),Sorts. <br /> I. Application Information—Please Print All Information <br /> Property Owner's Name / • Paned# <br /> 5441,0 Al 1 2 eN 07- -a-4D/6+-/o f-400-o/ya) _ <br /> Property Owner's Mallhtg Address ProPertYloaded ay. It)'. I 3 01 U <br /> 28996 fre Govt.Lot <br /> City,State Zip Code Phone Number � 1 l/., Y4,, Section 8 <br /> [/�1n1f7U�Y � Zi'1"x <br /> ' ✓ T li V N; R /O care E of <br /> II.Type of Buildi(g(check all that apply) Lot# ,/ <br /> cil I or 2 Family Dwelling—Number of Bedrooms 3 4— Subdivision Name <br /> Block# <br /> ❑Public/Commercial—Describe Use <br /> ❑City of <br /> ❑State Owned—Describe Use CSM Number C 0 Village of <br /> /57 viz P//✓ Town of aq,�lit,v <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' 0 New System Replacement <br /> y {�' ep System ❑Treatment/tioldisng Tang Replacement Only 0 Other Modification to ExistingSystem(explain) <br /> B. 0 Permit Renewal 0 Permit Revision 0 Change afPhmtber 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 /> 93 Nom-Pressurized in-Ground 0 Pressurized In-Ground 0 At-Grade 0 Mound>24 in.of snitable 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 Plow ) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Ares <br /> 1�(� � � Proposed(sf) System Elevation <br /> v . 7 6yo %9Ze626, <br /> VI.Tank Info ' Capacity ha Total *of Manufacturer " <br /> Gallons Gallons Units <br /> New Tanks Existing Tanks sir+ $ N .I. S <br /> k U vs os 1s a E <br /> Septic or Holding Tank /DO /ke G,ii Oi . / ,/ <br /> Dosing Chamber <br /> /->/✓V /` <br /> VII.Responsibility Statement-I.the undersigned.assume responsibility for Installation oldie POWTS shown on the attached plans. <br /> PIu 's Name(Print) i Plumber's MP/MPRS Nusysber Business Phone Number <br /> o.:4 <br /> - kr* *Ifav 16195-17/ , 76--fg-e.2.02 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 038I vMM-,'i 1 Ie i f (,J - L'; 55/P9 3 <br /> VIMI.County/Department Use Only <br /> Inning Alias MIMI= <br /> A Approved El Disapproved Permit Dery Issued <br /> 0 Owner Given Reason for Denial s LI 2 5- ZJ Z g1Z021{ 0 t / <br /> IX.Conditions of Approval/Reasons for Disapproval bbCC <br /> [rife- au if a b aV 1,P7u8 .. <br /> f Dw a) Gtx,l,i4 aid S-rt-& retr vrreiyitivis I .ECEMEt. <br /> Atomism complete pleas for the system and submit to the Camay only an monist tern drier II in i Il hales kati b <br /> Burnett County <br /> SBD-6398(R.08114) — Land Services Department <br />