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ar...';+r� <br /> �,f��^^ '�s Industry Services Division County <br /> tadi <br /> z, \c,, 1400 E Washington Ave �f <br /> `ffi P =` P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> 'try\ :l $ „ix! Madison,WI53707 7162 Af— ._79 <br /> ..P;htTnv;' (ST QL3-1 0 <br /> State <br /> Sanitary Permit Application <br /> I <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(I)(m),Stets. <br /> I. Application Information—Please Print All Information 3/ 172 kid./1.,/ <br /> Property Owner's Name 4 Parcel# <br /> erice (I M e O7-t 'Z-2-4r/4-Q-y D/-d -CNIaU _ <br /> Property Owner's Mailing Address 5a 3 Property Location A- 327 <br /> Z!C%Z ;r/Q/tie_,/ Govt.Lot .X�+ �C <br /> City,State Zip Code Phone Number , /Z <br /> [� / / /U� l�, 5E /i Section <br /> R'YZG(/�feej wr 535�" (facie one) <br /> IL Type of Building(check all that apply) Lot# T N; R fb E ore <br /> 1 I or 2 Family Dwelling—Number of Bedrooms r4 Subdivision Name <br /> Block# <br /> ❑Public/Commercial—Describe Use 0 City of <br /> ❑State Owned—Describe Use CSM Number ❑Village of <br /> '!Tovm of 5W's5 <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. satNew System 0 Replacement System 0 Treatment/Holding Tank Replacement Only0 Other Modification to ExistingSystem(explain) <br /> W YeP Ysg eP Y ( P ) <br /> B. 0 Permit Renewal 0 Permit Revision 0 Change of PlumberList Previous Permit Number and Date Issued <br /> g 0Permit Transfer to New <br /> Before Expiration Owner <br /> t 1 <br /> IV.Type of POWTS System/Component/Device: (Check ail that apply) <br /> 0 Non-Pressurized In-Ground 0 Pressurized In-Ground 0 At-Grade 0 Mound>24 in.of suitable 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 Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 906 . 7 iz ize 9/.0 <br /> VI.Tank Info Capacity in Total 1 of Manufacturer <br /> Gallons Gallons Units .o 2 o U T, <br /> a u <br /> New Tanks Existing Tanks c u v 12 .' <br /> ILI <br /> at:U rn y d) Ls 42 v a <br /> Septic or Holding Tank ZOev / I,�/�'`� l/ / <br /> Dosing Chamber J + <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plu cr's Name(Print) i Plumber's Si MP/MPRS Number Business Phone Number <br /> (Of.* Vfldel 4-,-> 86/962/ 7/1--IV-02O2, <br /> Plumber's Address(Street,City,State,Zip Code) <br /> e'8( vh n/ Ile 41 (A1e4/ er LA 91469, <br /> VIII.County/Department Use Only <br /> Approved 0 Disapproved Permit Fee D Date Issued 2Z! 4?I <br /> CIOwner Given Reason for Denial 5I1 (/0/23 <br /> IX.Conditions of Approval/Reax ns for Disapproval <br /> i11e4 0,11 4 S}��c '(el/rleii'l3 --. ->+.4._. _ . ,.,Th, <br /> 7 <br /> • <br /> Attach to complete pleas for the system and submit to the County only on paper not less than Sir t incifirfSr`sirlr 2 2023 j <br /> a513 Burnett County <br /> Land Services Department <br /> SBD-6398(R.08/14) $cash--. <br />