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County <br /> r� Industry Services Division L3 LA-r r 6 <br /> 1400 E Washington Ave <br /> - 9 Sanitary Permit Number(to be tilled in by Co.) <br /> P.O. Box 7162 chili - —17q <br /> Madison, WI 53707-7162 / <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 PO4VfS 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(I)(m),Stats. <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# -h 05� eal <br /> o-roaa-d-4& <br /> f�0µ Er,e 1450►, - c, 76VO <br /> Property Owner' fai �hG ling Address Property Location 77/7 <br /> 03 il <br /> I Ca l^< 1 J c-t 5-1' Al L Govt.Lot <br /> City,State Zip Code Phone Number /, %, Section 33 <br /> 16W L14 j[-t bej (circle one) <br /> II.Type of Building(check all that apply) �,j J Lot# T N; R E or� <br /> ❑ I or Family Dwelling-Number of Bedrooms ✓ Subdivision Name <br /> Black# <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of <br /> l/ -3 Town of Qak/Ak+el <br /> III.Type of Permit: (Check only one box on line A. Complete line 13 if applicable) <br /> A. <br /> New System ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. El Permit Renewal ❑Permit Revision El Change of Plumber ❑Permit Transfer to New <br /> List Previous Permit Number and Date issued <br /> Hefbre Expiration Owner <br /> W..Type.of POW YS.S stem/Com onent/Device: (Check all that apply) <br /> Pg razed In-Ground El Pressurized In-Ground ❑ At-Grade ❑ Nfound>24 in.of suitable soil El Mound<24 in.of suitable soil <br /> r <br /> El'HIdmTTaak ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> rs r <br /> VSDi ersaI/Treatment Area Information: <br /> Deii"gn'lhovi(gpd) Design Soil.Application Rate(gpdsf) Dispersal Area Required(st) Dispersal Area Proposed(st) System Elevation <br /> Ys71 <br /> VI.Tank Info Capacity in Total #of Manufacturer v <br /> Gallons Gallons Units o <br /> New Tanks Existing Tanks or; v ° o <br /> n,U Cn ti cn u V a <br /> Septic or Holding Conk )( <br /> /d /ego / .ZM ��.-a �'o� <br /> Dosing Chamber <br /> VII.Responsibility.Statement-I,the undersigned,assume responsibility for installation of the PO�VTS shown on the attached plans. <br /> Plumber's Name(Print)) Plumber's <br /> Signature � MP/MPRS Number Business Phone Number <br /> Plumber's Address(5tree,City,State,Zip Code) \ <br /> Vill.Coun /De artment Use Only <br /> Approved Disapproved Permit FSeeoo Date <br /> Issued u g gen 'gn e <br /> ❑ Owner Given Reason for Denial (/J ` 1/;3 ftu' <br /> I<(. �Conditionsof Ap vasons for Dis pproval <br /> ✓net- ll � O(+�'�_ -F � <br /> AUG 2 8 2023 <br /> Burnett County <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 in x I i ches i epar me <br /> CRn_�tas rpna t a� <br />