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County <br /> Industry Services Division 13uNh g(� <br /> r�. <br /> ,kf s it .; '= 1400 E Washin ton Ave <br /> 9 Sanitary Permit Number(to be tilled in b�y,C�o.+) <br /> P.O. Box 7162 23-1 10 <br /> C�k/�Ia <br /> ' 4 Madison, u</I 53 70 7-7 1 62 �!Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this fore to the appropriate govemmental unit <br /> is,required prior to obtaining a sanitary permit. Note;Application forms for state-owned PO4VTS are submitted to Project Address(if different than mailing address) <br /> the Department of Safety and Professional ervies. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy La iv,s.15.04(1)(m),Stats. <br /> I. Application Information-Please rfntAllInformation <br /> Property Owner's Name ParfN; R <br /> _y u3.Opn- O OG <br /> aT <br /> Jerl' Sulllvah <br /> Property Owner's Mailing Address Property <br /> -7 Pro11g�fd Sf'�tl° RO' ( GoCity,State Zip Cade Phone Number ction /(0 <br /> �vGn-fs�r^r � S'Q cleoneII.Type of Builrlin (check all that a ply) Lot# T E 0 <br /> I or Family Dwelling-Number of B edi ooms Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CS Number p Village of <br /> KTown of W,90A �1 <br /> IIL Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. . <br /> ❑New System J4 Replacemei it System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. El, Permit Renewal ❑Permit Rev sion ❑Change of Plumber ❑Permit Transfer to New List Previous Permit N`um/berand Date Issued <br /> Before Expiration Owner <br /> IV..T 'e.of POW 3'S.S stem/Com one t[Device: (Check all that appl i <br /> Non=Pre`e <br /> unsszed In-Ground ElPressu ed[n-G ❑ El At-Grade Mound>24 in.ofsuitable soil Mound<24 in.ofsuitable soil <br /> - - <br /> ❑ €Igld.-Tank ❑Other Dispersal Comp went(explain) ❑Pretreatment Device(explain) <br /> V Ds er sal/Treatment Area Informal on: <br /> D6s Fg TIN,(gpd) Design Soil Applicati n Rate(gpdsf) Dispersal Area Required(st) Dispersal Area Proposed(st) System Elevation <br /> 300 600 600 5 �1• <br /> VI.Tank Info Cap city in Total #of Manufacturer <br /> U <br /> Gallons Gallons Units � E� a <br /> New Tanks Exis[ingTanks o v <br /> C.,U f/7 N v] <br /> Septic or Holding Tank /tq0 0 DO 0 <br /> Dosing Chamber_ 600 �� VV <br /> VII.IPesponsibility.Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signatur IVIP/NIPRS Number Business Phone Number <br /> 7 Z6—"//SS <br /> Plumber's Address(Str et,City,State,Zip Cod ) i \ <br /> 776d <br /> VIll.County/Department Use Only <br /> AApproved ❑ Disapproved Permit Fee Date Issued Iss a Age ignature _ <br /> ❑Owner Given Reason for Denial <br /> IX.Con hons of Appr. va easons for Disapproval <br /> �Qro rr y 1,45 AP �e 1)70CL.4. F ,rul e car '� �elcl s4� AU6 10 2023 <br /> Y/a s v,A s� b w,l Ike* <br /> ��� 9. Burnett County <br /> Attach to complete fans for thesystem and submit to the County only on paper not less than 8 in x 11 es eparimerrt <br /> CRn_Aioe rvnzt-n <br />