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Industry Services Division County Q <br /> 1400 E Washington Ave p U(N� <br /> '='( P.O.Box 7162,- nary Feanit Number(to be filled in by Co.) <br /> Madison,WI53707 7162 _ 7 <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 PO WTS 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 t purposes in accordance with the PrivacyLaw,s.15.04 1 m),Stats. Z J� LjCf/W71 <br /> / <br /> 1'. Application Information—Please Print All Information t� ? ('L <br /> Property Owner's Name Parcel# l QX kb J�j�p31 <br /> W"(k- Sqkel- 07-0�0-i?-&J-V4 0;7-*-V <br /> Property Owner's Mailing Address Property Location <br /> Iwo �(alQ, t�l Vn Govt.Lot <br /> City,State Zip Code Phone Number y,, % Section Z7 <br /> 0 eNo CtZ,j� (circle one) <br /> H.Type of Building(check all that apply) Lot T 7 e7 N; R /I Eo& <br /> 1 or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of_ <br /> Wd !Oftz Town of L'j C (1'r d <br /> 111.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. New System Replacement System Treatment/HoldingReplacement Only Other Modification to Existing System(explain) <br /> $• ❑Permit Renewal ❑Permit Recision ❑Change of Plumber ❑Permit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: Check ail that a ! ) <br /> (Pon-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑Mound 2:24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dis ersaIlTreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 306) 1 --1 1 ya(� 1 //,79, 1 T qY t 3 <br /> VI.Tank Info Capacity in Total n of Manufacturer <br /> Gallons Gallons Units o E E <br /> New Tanks Existing Tanis <br /> c.U in u 0 a. <br /> Septic or Holding Tank n�1 di,r� w <br /> =4=- <br /> Dosing ChmWoer r l/ GEC/ /r <br /> VI1.Responsibility Statement-L the undersigned,assume responsibility for hrstallation of the POWfS shown on the attached plans. <br /> Plu cr's Name(Print) Plumber's ' We MP/MPRS Number Business Phone Number <br /> Plumh-r's Address(Street,City,State,Zip Code) <br /> i0bgl 140A w z ie Wel Qebo/v- Vt.- s��q <br /> VIII.CounVIDepartment Use Only <br /> Approved ❑Disapproved Perraiil Feed �Df at issued issuin gent Signal= <br /> ❑Owner Given Reason for Decrial S <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Nte4 aUSefbaft�s GIB J2?l9 <br /> aU (a4/71y aj� sm-k re f ui fe ww�s nn I G F 0 v E. <br /> Attach to complete plans for the system and submit to the County only on paper not lass than 8 t1l x I ine a12 <br /> [� Burnett County <br /> SBD-6398(R.08114) Land Services Department <br />