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`al" Industry Services Division County <br /> /57 8 " \ 1400 E Washington Ave Dr <br /> (:`:,`Srg ;;: P.O.Box 7162 _Sanitary Permit Number(to be filled in by Co.) <br /> i. Madison,WI 53707 7162 • 5 -z�—q 7 <br /> L` i_ o;, <br /> �, ate`' l.--.24-43 (4)585aoZ <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 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),Stats. <br /> I. Application Information-Please Print All Information TUX f t ?5J _ <br /> Property Owner's Name / Parcel# <br /> 1`c 'e Top/9-6 /l-1+0-14'-ai-fi i5-X✓-053' <br /> Property Owner's Mailing Address / Property Location <br /> 57 7 (AiQyt /ci ri 7t Govt.Lot <br /> City,State Zip Code Phone Number 2 L <br /> tt-- II //�- / 11 /., /�, Section`,�W41q 49 /r/r 55981 - T 70 N; R /el lEonn <br /> II.Type of Building(check all that apply) Lot <br /> II or 2 Family Dwelling-Number of Bedrooms Z 7✓ Subdivision// Name ,/�� 1, r/I, <br /> Block R 5�y/1 N/�6j'/6viXAl7' !z' t/i <br /> o Public/Commercial-Describe Use 0 City of <br /> ❑State Owned-Describe Use CSM Number 0 Village of ''" <br /> TownSit of 7+Gkyooa <br /> Ill.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. 1ii <br /> e New System 0 Replacement System 0 Treatment/HoldingTank Replacement Only0 Other Modification to ExistingSystem(explain) <br /> Y� YCP Ys eP Y (•P ) <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 /> CfNon-Pressurized In-Ground 0 Pressurized In-Ground 0 At-Grade 0 Mound 24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑ Holding Tank 0 Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> • S 'oO 6 G O _T 10 651.o <br /> VI.Tank Info Capacity in Total #of Manufacturer v <br /> Gallons Gallons Units s, 47 o•$ <br /> New Tanks Existing Tanks • c v 2 y 1 a a <br /> a.u iii TA to is- 0 a. <br /> Septic or Holding Tank goo B I�' <br /> 00 I - ,Q I . V <br /> Dos mg Chamber � W m- <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Pl eer's Name(Print) i Plumber's Si 0.74 MP/MPRS Number Business Phone Number <br /> ,,.0(7 76/14/01.;94/ / g%795-gy 7/5=fg-02,O2 <br /> Plumber's Address(Street,City,State,Zip Code)S8( ,4i A/ tie 47 <br /> Webok- Li- 54159 3 <br /> VIII.County/Department Use Only <br /> Approved ❑Disapproved <br /> Permit Fee` Datea Issued /� Issuin gent Signaturejk <br /> ❑Owner Given Reason for Denial S Z 5 _ I d �i(JZ l � <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> too- ctu st,frbarAts 3 ECEVF -Th <br /> PP PP <br /> follow a C D urr& atd Is'4664 repulre.,m s -_,� <br /> 1.PR1r is ~"' <br /> Attach to complete plans for the system and submit to the County only on paper not less than it in x 11 nteti sf se ` <br /> Burnett County J <br /> Land Services Department <br /> SBD-6398(R.08/14) 11126 Cke el # / 2 71 7. <br />