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T '+ Industry Services Division Coun <br /> 1400 E Washington Ave ^,e ' <br /> Madison,WI53707 71(d <br /> { be 81,1e^d in b/y O 0 Co) <br /> tr' �' ILJJ� .)(f/ <br /> 0 <br /> �►i �. �� G g, <br /> 23 .. 11 J <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383Z1(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 Prtyect Address Of diftrent than ma03ng address) <br /> the Department of Safety and Professional Services.Personal inftimation you prmnde my be used for secondary 2?,5�2 <br /> Purposes in accordance with the Privy Law s.15.04 1 m Stars. C. w <br /> I. Apollcatlon Information-Please Print Ail Information <br /> Property Owner's Name pwcd# <br /> D /e r 1�/n�'I -o06-Z-3B/7-I%2 D/-ocao-o/ldGo <br /> Property Owner's Mailing Address Property Nation <br /> o /7 016,46 Govt Lot <br /> City,State Zip Coda Phone Number <br /> a A. Section � <br /> � frA) W/' 6Yb72 T %� N; R 16 one <br /> cim <br /> of <br /> II.Type of Building(cheek all that apply) Lot# <br /> al or2Fatnily-Dtvolling-WumborofBcdmains Z Subdivision Nam <br /> Block# <br /> ❑Public(Comniftai-Describe Use Q city of <br /> ❑State Owned-Describe Use CSM Number D Village of <br /> Town of_ 0M e;1 <br /> III.Type of Permit: (Check only one box on line A. Complete line B if sppUcable) <br /> " New System ❑ Replacement Y ep System Q Treatment/Holding Tank Replacement Only ❑Other Modification to ExistingSystem{explain} <br /> B- ❑Permit Renewal ❑Permit Rnision ❑Change of Plumber Q Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS S stemxora onent/Device: Check all that apply) <br /> ❑Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grude CrMound>_24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) Q Pretreatment Device(explain) <br /> V.Dis ersaWreatmem Area Information: <br /> Design Flow(gpd) Design Soil Application RateWdsf) I Dispersal Area Required(st) D Area Y r <br /> Proposed(sf) S Q p <br /> 30o � {StZO <br /> VI.Tank Info Capacity in oral #of Manufacturer <br /> Gallons Gallons Units B <br /> New Tanks Existing Tacks .g a <br /> U y at tL t7 i% <br /> Sc*or Holding Tank <br /> 44 <br /> DoftCbamber 5-6Q \ <br /> VII.Res onsibiitby Statement-1,the undersigned,assume 2spo billty br iaitailatioa of the POWTS shown on the attached plans. <br /> P u 's Ni;XUy <br /> Phnnbces S heft4 RS Number Business Phone Number <br /> M,,,/, <br /> Plumber's Address(S t,City,State,Zip Code) <br /> VIIL Coun /D rtment Use Only <br /> Approvcd ❑Disapproved Pt n 5� 10 nit Fee 00 Date 1 l <br /> 7 <br /> ❑Owner Owen)lesson for Denial ' <br /> I7C.Conditions of Appro s for DSI prsratt <br /> Mee+ c � 5-" �C� C0�lC <br /> n 0 C T 1 1 2023 <br /> Attach to eompleft plan:for the system and sahmit to the County only an papariot IMAM 110 311 sie <br /> Burnett County <br /> Land Services Department <br /> SBD-6398(P-08/14) <br />