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z�rpr- 4' .v County f� <br /> 4 Industry Services Division Y r <br /> . � .:•I# ;:;;..: ;,- 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> P.O. Box 7162 <br /> 'Z� / <br /> Madison, V•/I 53707-7162 I(e'5Q 946 <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 PObVTS are submitted to Project Address(if different than mailing address) <br /> the Department of Safety and Professional Servies. Personal information you provide may be 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# <br /> _ <br /> v7- .a 6Ja -'Y10' <br /> Tvt -erle,Sk P0bf�C b3loo0 <br /> Property Owner's Mailing Address p Property Location <br /> �9 0 3 b �v, `Y-e6w /2t v eV ��Ot Govt.Lot <br /> City,State Zip Code Phone Number y,, y, Section <br /> /_ _51�f,?.0 `a (circle one <br /> II.Type of Building(check all that apply) ) Lot# T / N; P E <br /> ❑ I or Family Dwelling-Number of Bedrooms h Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number Village of <br /> Townof Gk/L/RM pl. <br /> III.Type of Permit: (Check only one box online A. Complete line B if applicable) <br /> A' ❑New System p y p y y (explain) <br /> ❑Re Replacement System Treatment/Holding Tank Replacement Only ❑ Other iv[oditication to Existing System <br /> B. ❑ Permit Renewal ❑Permit Revision ❑Change of Plumber El Permit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.L e,of P0WTS.S stem/Com onent/Device: (Check all that app 1 ) <br /> Non P essunzed In-Ground ❑ Pressurized In-Ground ❑ At Grade ❑ Ivlound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑ Kgldmg Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V Ds ets tl/Treatment Area Information: <br /> Desi5,u�171ow(gpd) I Design Soil Application Rate(gpdsf) Dispersal Area Required(so Dispersal Area Proposed(st) System Elevation <br /> (go - Wr 's N is - St, s- <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units U <br /> New Tanks Existing Tanks o U a <br /> c U m H cn u=U G. <br /> Septic or Holding Tank /d/ O �r t Ili <br /> ✓���- �/ <br /> Dosing Chamber_ - V .L j <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 MP/MPRS Number Business Phone Number <br /> /7 ae_ <br /> Plumber's Address(Stre t,City,State,Zip Code) i \ <br /> VIll.Coun /De artment Use Onl <br /> pproved ❑ Disapproved Permit Fee Date Issued Issuing ent SignakIr <br /> ❑Owner Given Reason for Denial $ 3 7 ��L-3 nn UU <br /> IX.Conditions of�pptoval/Reas ns for Disapproval <br /> er, <br /> JU N 016023 <br /> 0375. <br /> Burnett County <br /> Attach to complete plans for the system and submit to the County only ou paper not less than 8 In s it i epartment <br /> SBD-6393 (Rn311) <br />