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..ttitwt�ui <br /> Industry Services Division County <br /> 9 �t� 1400 E Washington Ave LU��- <br /> P.O.Box 7162 <br /> Sanitary Permit Number(to be filled in by Co.) <br /> ' t Mattison,WI 53707 7162 �N_ <br /> --1/ P5095� <br /> Sanitary Permit AmEcation stare Transaction Number <br /> 1 L <br /> In accordance with SPS 38311(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit <br /> is required prior to obtaining a sanitary permit.Note,Application forts 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 <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Slats. )COW— <br /> I. ALpplication Information—Please Print All Information <br /> Property Owner's Name Parcel# <br /> l � arm �yai6- 3-T i5o�s-oz8� <br /> Property Owner's Mailing Address .1 - 1V Property Location <br /> dl `TL Govt.Lot 'L <br /> City,state Zip Code Phone Number y,, %i Section <br /> �c�rcle one)n <br /> T -/u U N; R /O <br /> H.Type of Building(check all that apply) Lot <br /> q1 or 2 Family Dtvelling-Number of Bedrooms Subdivision Name <br /> LL <br /> ❑ Blocky Public/Commercial-Describe Use r7 ❑City of <br /> ❑State Owned-Describe Use CSNI Number ❑Village of <br /> R Town of 0-q l Ad <br /> 111.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑New System <br /> y Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> $ ❑Permit Renewal ❑Permit Re�7sion t List Previous Permit Number and Date Issued <br /> ❑Change of Plumber ❑Permit Transfer to New <br /> Before Expiration Onner <br /> IV.Type of POWTS System/Component/Device: Check all that a iv <br /> CYNon-Pressurized in-Ground ❑Pressurized In-Ground ❑At-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dis ersaliTreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sfl Dispersal Area Proposed(sf) System Elevation <br /> 3� 600 6� -T <br /> VI.Tank Info Capacity in Total g of Manufacturer <br /> Gallons Gallons Units E o g <br /> New Tanks Existing Tanis v 3 a <br /> o.U en m U. a a. <br /> Septic or Holding Tank- 7fc <br /> 1. C <br /> Dosing Chamber YU 1/V <br /> VIl.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Zluvr's Name(Print) Plumb gnaturc MP/MPRS Number Business Phone Number <br /> Plumbers Address(Street,City,State,Zip Code) <br /> �59 I AvoAw I A 4/ (AJeb---2 <br /> VIII.Colin /De artment Use Only <br /> Approved ❑Disapproved Permit�� Date�e�� Issu. t Si <br /> ❑Owner Given Reason for Denial / <br /> IX.Conditions of Approval/Reason for Disapproval <br /> WIS KA <br /> I P PCE VF <br /> IM <br /> Attach to complete plans for the system and submit to the County anlv on paper not less than 8 V2 111 I i tit MAY <br /> Burnett County <br /> SBD-6399(R.08114) Land Services Department <br />