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r i���q, Industry Services Division County <br /> ,�1 1400 E Washington Ave g�N - <br /> ;t 1! , P.O.Box 7Ib2 f , Permit Number(to be filled in by Co.) <br /> b\ �iit: Madison,WI 53707 7162 013 - NO //� <br /> �fran`,' C — -122 �541.2, <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this Eden to the appeopriate governmental unit <br /> is required prior to obtaining a sanitary pest.Note Application forts for state-owned POWl'S are submitted to Project Address(if different than mailing address) <br /> the Department of Safety and Professional Services.Personal infr malice you provide may be used for secaodary <br /> purposes in accordance with the Privacy Law,s.15.04(1Xm),State. a/ <br /> I. Application Information-Please Print AD Information :f!D 8 3 Craxidatr Nice <br /> Property Owner's Name —Parcel* <br /> Property Owner's Melling Address Property location1:1---7 3'U <br /> 55 C,itrry err Al Lot <br /> City,State Zip Code Phone Number y; yy Section /3 <br /> MN W 5 0/b /, cr•mle oat <br /> II.Type of Building(check Athat apply) t:.ot T 7 N: R ��j� E or + <br /> tr I or 2 Family Dwelling-Number of Bedrooms 3 /5- Subdivision Name <br /> Block# 6re2fB .�l4�f0 UY <br /> O Public/Commacial-Describe Use <br /> 0 My of <br /> 0 State owned-Describe Use GSM Number 0 Village of <br /> Town of J Qc kdgiON <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. 5New System 0 Replacement System 0 Trtatment/Holding Tank Replacement Only 0 Other Modification to ExistingSystem(explain) <br /> B- 0 Permit Renewal 0 Pantie Revision 0 Change of Plumber 0 Permit Transfer to New list Previous Permit Number end Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) • <br /> l Non-Pressurized In-Ground 0 Pressurized In-Ground 0 At-Grade 0 Mound>24 is ofsniteble soil 0 Mound<24 in.of suitable soil <br /> ❑Holding Tank 0 Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> V.Dispersal/Treatment Ares Information: <br /> Design Flow(gpd) Design Soil Application Rate(pgndsf) Dispersal Area Required(at) Dispersal Area Proposed(at) System Elevation <br /> f5 , 7 07 Ede WO <br /> VI.Tank Info Capacity is Total t of ManufacturerGallons Gallons Gallons Units .° E $ ^ i <br /> New Tanks <br /> too Existing Tanks 6 `U � 1 �F7 a <br /> Septic or That to met) / Ui I ever <br /> Dosing Clamber <br /> VII.Responsibility Statement-i,the undersigned,assume responsibility for lasaamtion attire pewee shown ea the attached plans. <br /> Pl 's Name Tint) Plumber's MP/MPRS Nmpbe Business Phone Number <br /> ffi 6V95-/ 7/1"--Vd-$1.242 <br /> Plumber s Address(S City,State,Zip Code) <br /> 0881 wM' C k � Wks, ,i. 51ig 9 3 <br /> VIII.Connty/Department Use Only <br /> %Approved 0 Disapproved Permit Fee Date Issued rsrto, <br /> 0 Owner Oren Reason for Denial S Li 5 0161123 <br /> IL Conditions of Approval/Reasonsfor Dsapproml <br /> Mee- Ail .5e—b 544c 174447‘eireid5 <br /> lECEINE-1 <br /> Attach to ample&pleas for the system sad submit tedeeC only aa paper astteathanatn=t1!aehes hare M#1; 8 1 2023 'th <br /> Burnett County <br /> Land Services Department <br /> SBD-6398(IL 08/14) C{, _ !, *I t 259 lit./Z5 <br />