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rixr �} County Department of Safety jZ <br /> & Professional Services, i�J"' <br /> Sanitary Permit Number(to be filled in by Co.) <br /> Industry Services Division <br /> 10541 g-39 <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 <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Slats. <br /> I,Application Information Please Print All Information wry a S 45� -A -�S ��/ <br /> Property Owner's Name Parcel � <br /> p y pl_ 2g-2 AID-ly-18 5 DS-ov�-plboa <br /> 4 (L a E rr- o a L0 1 '?v 111 <br /> Property Owner's Mailing Address y� Property location <br /> 1�" T( O L e m/L Govt.Lot <br /> City,State Zip Code Phone Number <br /> J 6 L/4 t!t [1 f /., /., Section OY <br /> IL Type of Building(check;all that apply) Lot# � T �� N R 1 L( E o,19 <br /> or 2 Family Dwelling—Number of Bedrooms Subdivision Name <br /> Block# <br /> ❑Public/Commercial—Describe Use <br /> ❑City of <br /> ❑State Owned—Describe Use CS�M Number ❑Village of <br /> lit?t? V i l P 5 Town of <br /> Ill,Type of POWTS Permit:(Cheek either"New"or"Replacement"and other applicable on line A. Cheek one box on line B.Complete line C It <br /> applicable.) <br /> A. <br /> ❑ New System �-lteplacementS*m%W ❑ Other Modification to Existing System(explain) ❑ Additional Pretreatment Unit(explain) <br /> JK <br /> B' ❑ Holding Tank ❑ In-Ground ❑ At-Grade Design Type(explain) <br /> ❑ Mound Individual Site Desi Other T e <br /> (conventional) s/K 0 <br /> C. ❑ Renewal Before ❑ Revision ❑ Change of Plumber ❑ Transfer to New Owner ist Previous Permit Number and Date Issued <br /> Expiration <br /> IV,Dispersalfrreatment Area and Tank Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpd/sf) Dispersal Area Required(sf) Dispersal Area Proposed(so System Elevation <br /> 730 o 61k5i', A 6 <br /> Capacity in Total #of Manufacturer <br /> Tank Information Gallons Gallons Units U U ti <br /> New Tanks Existing Tanks a 2y p <br /> / ci U in v rn <br /> Septic or Holding Tank J '�SO ` e .5 <br /> Dosing Chamber <br /> V.Responsibility Statement-1,the undersigned,assume reVomJt##Qor installation of the POWTS shown on the attached plans. <br /> Plum s Name(Print) Plumber's Si ature MP/MPRS Number Business Phone Number <br /> �/ /L c l) �s �v �s�16 i6 Io <br /> Plumber's Address(Street,City,State,Zip Code) <br /> VL County/Degartment Use Only <br /> Approved ❑Disapproved <br /> Permit Fee Date Issued Lssuin Agent Signature <br /> $ J��= <br /> ❑Owner Given Reason for Denial <br /> Conditions of Approval/Reasons for Disapproval <br /> f o l toL- Ct U cck,+`l cJ S-Wk- re.�revl�c;�,ti�S � E V Ct <br /> AU6 14 2023 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x I I nehes i <br /> Burnett County <br /> Land Services Department <br /> SBD-6398(R.03/22) <br />