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ilI Department of Safety County <br /> 4 v & Professional Services, <br /> s _ Sanitary Permit Number(to be filled in by Co.) <br /> Industry Services Division �3--,2t i <br /> fi.RCNhv <br /> (1-15-10/7 <br /> Sanitary Permit Application State Transaction Number <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 o9o�ioa y f�Otn9tonS P f <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# <br /> Lynnae [At kIM / UN7,kt: Ne++leS 0 7-o'Ia -s- :S-z7(v- O �hc <br /> Property Owner's Mailing Address Property Location <br /> 1 71 Z t o h 16t, 7-1 W Govt.Lot <br /> City,State Zip Code Phone Number <br /> C. IZc; 1 A, 1v1 li SS r-13 3 1-z Z 8-3`.A - 780( �' /y, Section Y I/ <br /> II.Type of Building(check all that apply) Lot# T 3 S N R !C E or <br /> 1 or 2 Family Dwelling-Number of Bedrooms Z Subdivision Name PCt V <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of pp <br /> LJTownof 4,LJ°od F+4Cr <br /> III.Type of POWTS Permit:(Check either"New"or"Replacement"and other applicable on line A. Check one box on line B.Complete line C if <br /> applicable.) <br /> A. <br /> ❑ New System � Replacement System ❑ Other Modification to Existing System(explain) ❑ Additional Pretreatment Unit(explain) <br /> B' Holding Tank ❑ In-Ground El At-Grade ❑Mound ElIndividual Site Design ❑ Other Type(explain) <br /> (conventional) <br /> C. ❑ Renewal Before U Revision U Change of Plumber ❑Transfer to New Owner ist Previous Permit Number and Date Issued <br /> Expiration 1 N v <br /> IV.Dispersal/Treatment Area and Tank Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpd/st) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> Capacity in Total #of Manufacturer <br /> Tank Information Gallons Gallons Units U <br /> New Tanks Existing Tanks c ° Y p <br /> rS; U in rn ii 0 p.. <br /> Septico oldie 'lio�� Yo <br /> LAD; See- <br /> Dosing Chamber <br /> V.Responsibility Statement-1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Si ature MP/MPRS Number Business Phone Number <br /> jt,1.- - &o ,ese„ IDY7�' 7/5- '163-3'1'? <br /> Plumber's Address(Street,City,State,Zip Code) Q <br /> ,�:% 1. <br /> VI.County/Department Use Only <br /> Approved ❑Disapproved Permit Fee Date Issued Issuin Agent Signature <br /> ❑Owner Given Reason for Denial <br /> 3�5 9 �27 f Z3 <br /> Conditions of Approval/Reasons for Disapproval <br /> r CE CCU E Q IE <br /> A/t.d 'Oak �e �.�r� m.��l <br /> �tllow G� <br /> SEP 2 7 2023 <br /> Burnett Countv <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 11 inLkt&Ch�tiwviceS Department <br /> SBD-6398(R.03/22) <br /> C'_ I o 4 0 <br />