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Industry Services Division Canty <br /> 1400 E Washington Ave U f � <br /> }I.� P.O.Box 7162 Sanitary permit N (to be filled in by Co.) <br /> Madison,WI53707 7162 <br /> fit;,..•ram,;` 023 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 38321(2).Vic Adm.Code,submission of this form to the appropriate governmental unit <br /> is required prior to obtaining a sanitary permit Note:Application forms for atatc-owned POWTS am submitted to Project Address(if different than mailing address) <br /> the Department of Safety and ProfeWo rial Services.Personal iafaamation you provide may be used hr secondary <br /> ases in accordance with the Privacy Law S.15.04(1)(m Stats.I. 76 86 G <br /> A ll In <br /> lication Information—PIeam Print AA <br /> Property Owner's Name / / Patcel# <br /> �cf "77 e,;Nk10 o7-+�i8-Z -�6-a8-z orb-Cj2crx, <br /> Property Owner's Mailing Address Pity Location 0 31 <br /> 23 75 �e4{l�/�/ Govt.Lot <br /> City,State Zip Code Phone Number Y; Section 8 <br /> yi�'er.S Sy$7Z T N. R�tarele one), <br /> U.Type of Building(check all that apply) Lot# <br /> El 1 or 2 Family DvmH4—Number of Bedrooms Z 2 Subdivision Name <br /> Block# <br /> ❑Public/Commercial—Describe Use 11 City of <br /> ❑State Owned—Describe Use CSM Number ❑Village of ,s�I <br /> 9Tmvnof /77eeHD�J <br /> Ill.Type of Permit: (Check only one box an line A. Complete line B if applicable) <br /> A. ❑New System O(R iacement ep System ❑Treatment/Holding Tank Replacement Only 13 Other Modification to Existhtg5ystem(explain) <br /> B- ❑Permit Renewal Q Permit Recision ❑Change of Plumber Q Permit Transfer to Nov list Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS S tem/Com onent/Device: Check all that apply) <br /> ❑Non-Pressur zed 1n-Ground ❑Pte3surized la-Ground ❑At-Grade Q Mound>24 in.of smitable soil 0 Masud<24 in of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) Pretreatment Device(ccpwm) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Sort Application Rate(gpdst) Dispersal Area Required(sf) Dispersal Area P at)Proposed( System Elevation <br /> Foe) I ADO 3Do q�.S <br /> VL Tank Info Capacity is Total #of Manufacturer <br /> cahoots Gallons Units <br /> New Tanks Existing Tardy <br /> Septic or Holding Tank 7CJ <br /> Dosing Cbamber 5M <br /> VII.Responsibility Statement 4 the undersigned,assume responsibility for tastailation of the POWTS shown on,the attached plans. <br /> Plu er's Name(Print) Plumbees Sigual#c MP/MPRS Nripber I Business Phone Number <br /> Plumber's Address(S k City,State,Zip Code) f <br /> VIlL County/Departmient Use Only <br /> Approved ❑Disapproved Petadt Fee 2p Date <br /> /lsQ�wd <br /> ElOwner Given Rom for Denial S q <br /> IX.Contlitions otApproval/Reasons for Disapproval <br /> IID <br /> n OCT 0 3 2023 <br /> Attach to tompiete plans for the system and submit to tux tomy a*an taper net tee tbn ti tni s it h40, <br /> Burnett County <br /> Land Services Department <br /> SBD-6398(R.08/14) <br />