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in7%.,..,_q_,,,_ Industry Services Division County, 1400 E Washington Ave &at/ <br /> (#1.,S! P.O.Box 702 Sanitary Permit Number(to be fined in by Ca) <br /> 4. �; Madison,WI53707 7162 N-J3 143 4 yy,J/1 t71' <br /> Sanitary Permit Application S 'on Number <br /> In accordance with SPS 383.21(2).Wu.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 maybe used for secondary <br /> purposes in accordance with the Privacy Law s.15.04(1)(m),Stats. <br /> I. Application Information-Please Print Ail Information <br /> Property Owner's Name /� Parcel <br /> /�aWn1 �-f!' of-q'140-15 Zy-S alta-aba ) <br /> Property Owner's Mailing Address Property Location <br /> 2771/ /110 etled Govt.Lot <br /> City,State Zip Code Phone Number ,,,, y., Section 2 9 <br /> T 'fO N; R 14 Eor) <br /> IL Type of Building(check ail that apply) tot# <br /> Er!or 2 Family Dwelling-Number of Bedrooms // Subdivision Name <br /> Block# <br /> 0 Public/Commercial-Describe Use Q <br /> CIty of <br /> ❑State Owned-Describe Use CSM Number 0 Village of <br /> Vg �� V Town of T4c�o9 <br /> III.Type of Permit; (Check only one box on line A. Complete line B if applicable) <br /> A. 0 New System I'Replacement <br /> siu System _0 Treatment/Holding Tank Replacement Only 0 Other Modification to ExistingSystem(explain) <br /> B. 0 Permit Renewal Q Permit Revision 0 t3anr of Plumber 0 Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner !02 3 7 <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> Eil 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(=plain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> I/50 . 7 , 61/z 61r8 IIz5 8q/ <br /> VI.Tank Info Capacity in Total *of Manufacturer <br /> Gallons Gallons Units a i ti 0 <br /> New Tanks Existing Tanks ' <br /> Sepdcor Holding Tank /046 /066 z lint/ r r Y <br /> Dosing Chamber <br /> VU.Responsibility Statement-I.the undersigned,assume responsibility for lnstaliation of the POWTS shown on the attached plans. <br /> PL <br /> Name(Print) 1 Plumbers MP/MPRS Number Business Phone Number <br /> iff 1/ , /7 fl6'I 7/c—fi(•02 )2 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> OS8I ivy{ 1/ Al tub er- t,J; 5'/ 93 <br /> VIII.County/Department Use Only <br /> L,Approved ❑Disapproved PatatitFa: Date hated <br /> T <br /> Q Owner Given Reason for Denial S I v 2S 0/9/a3 a" (-- ,;-,(t, <br /> IX Conditions of Approval/Reasons for Disapproval r .fIVEU <br /> !'►lee4--a u 9 ift c'v " + S-i^,t, ►' ifirvn - i 0 8 2023 <br /> Attach In complete pleas for the system and submit to the Caantyr only on paper stet less than a tri s II Indus is <br /> Burnett County <br /> Land Services Department <br /> ng26' c-lAc_k it t Z1c05S <br /> SBD-6398(R.08/14) <br />