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County <br /> tT — Industry Services Division U U r h <br /> f ton Ave 1400 E Washington Sanitary Permit Number(to be titled in b Co. <br /> -Box 7T - <br /> rx; Madison, WI 53707-7162 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this Conn to the appropriate goveminental 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 Servies. 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 All Information <br /> Property Owner's Name Parcel# O 0 p o <br /> e�� �l e-es -@its-),-3-7 0 3 �/ <br /> o/S'000 <br /> Property Owner's Mailing Address Property Location It v-3 <br /> �)'Jr' N Govt.Lot <br /> City,State ISZ3­0 <br /> ip Code Phone Number y, '/,, Section <br /> tn 0 /YIN 3 8 circle one) <br /> II.Type of Building(check all that apply) Lot# T 9 N; R /� E ore <br /> ❑ 1 or Family Dwelling—Number of Bedrooms 3 Subdivision Name <br /> Block# <br /> ❑Public/Commercial—Describe Use <br /> ❑ City of <br /> CSM Number Village of <br /> ❑State Owned—Describe Use ❑ <br /> ❑ Town of <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑Re Y P Y Y. (explain) <br /> New System placement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System ex lain) <br /> B. ❑ Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IT f e.of P(3WTS.S stem/Com ponent/Device: (Check all that apply) <br /> Non['ass ized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil El Mound<24 in.of suitable soil <br /> ❑EIo[dm�Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> VjDis et al/Treatment Area Information: <br /> Des1gn71low(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> yS-a 3— qoo �ioo 9yq to 93• cl <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> U <br /> Gallons Gallons Units U h N <br /> New Tanks Existing Tanks L o ? <br /> a U cn ti rn w U a <br /> Septic or Holding Tank /10 b Q �d G l �h/`l�f'-�✓N t(>✓ <br /> Dosing Chamber- <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature IVIP/MPRS;Number Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) ` <br /> 7760 /�,_, .s- <br /> V111.Coun /De artment Use Only <br /> Approved ❑ Disapproved Permit Fee Date Issued Issuing A ent S, a <br /> ❑ Owner Given Reason for Denial <br /> /a�3 - <br /> IX.Coneediti ns of Approval/Reasons for Disapprovpl <br /> e Burnett County <br /> Land Services Department <br /> -S75 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/?x II inches in size �p <br /> CRrI_�1nQ io n�i�� <br />