Laserfiche WebLink
•�J==-"i�.1 Industry Services Division County <br /> f 1400 E Washington Ave (N - <br /> ,cr <br /> P.O.Box 7162 <br /> Sp Sanitary Permit Number(to be filled in by Co.) <br /> ' t S �K: Madison,WI53707 7162 <br /> t4_ -23 -1 b. <br /> Sanitary PGI'ni t Application state Transaction Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this fort 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 <br /> purposes in accordance with the Privacy Law,s.15.04(I)(m),Stats. 8 f <br /> I. A lication Information-Please Print All Information <br /> Property Owner's Name � Parcel# <br /> kl_ckr� a 'w-ill-lb-31 .oat-01zIoo <br /> Property Owner's Mailing Address 17t7�� Property Location -( /j :a= Z,4 <br /> )( fl 6 GovL Lot <br /> City,State Zip Code Phone Number 3Z <br /> ff /,, Section <br /> ,00!l�t�1�UY W t T N: R L(circle one),-? <br /> y� _lt� or <br /> II.Type of Building(check all that apply) Lot i* <br /> i or 2 Family Dtvelling-Number of Bedrooms �- Subdivision Name <br /> Block 4 <br /> ❑Public/Commercial-Describe Use ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> °1 PIV I�IToum of �v vJt <br /> —Vl <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> New System ❑ Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> 13. ❑Change of Plumber List Previous Permit Number and Date Issued <br /> ❑Permit Renewal ❑Permit Recision Q Permit Transfer to New <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: Check all that apply) <br /> Non-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.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 34a �1Z y i yZ� 892.E <br /> VI.Tank Info Capacity in Total n of Manufacturer <br /> Gallons Gallons Units <br /> New Tanks Existing Tanks <br /> a U lit � m u. t7 a <br /> Septic er Holding Tank G T+L— `X, <br /> Dosing Chamber <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for Installation of the POWTS shown on the attached plants. <br /> Plua er's Name(Print) Plumber's Si MP/MPRS Nutpber Business Phone Number <br /> l(/ Tlr4�� <br /> Plumber's Address(Street,City,State,Zip Code) <br /> G f Avo Aw I A 41 (AJebSA-,- V,. 5L(69 <br /> VIII.Coun /De artment Use Only <br /> Permit Fee Date Issued Issuing eat Signature <br /> Approved Disapproved S <br /> ❑Owner Given Reason fur Denial <br /> IX.Conditions of App ovaUReasons for Disapproval <br /> Wei a l� S Tc, FnD - <br /> FOEWE <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 tf2%11 lakes 1 J U N 2 7 2023 <br /> Burnett County <br /> SBD-6398(R 08/14) Land Services Department <br />