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_ ,,•,� ,z-��.,.�. Fy <br /> Industry Services DivisionVf <br /> 1400 E Washin ton Ave - umber to be tilledinb Co.P.O. Box7152 � / <br /> Madison, WI 53707-7162 ��b W7 <br /> —�3 -.2� <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 fortes for state-owned PO4VTS are submitted to Project Address(if different than mailing address) <br /> the Department of Safety and Professional Servies. Personal information you provide maybe used for secondary )8 <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),S tats. a� <br /> I. Application Information—Please Print All Information <br /> Over /qua/ 7rw,' r (uti <br /> Property Owner's Name Parcel# S /.SS —S(.o <br /> a2 <br /> Property Owner's Mailing Address Property Location <br /> �t{UG7 Gt/-eodA Govt.Lot <br /> City,State �� Zip Code Phone Number /, %, Section ,A 3 <br /> ?u r►e t a 9!7 3 9 (circle one) <br /> U aim " T 410 N; R -1 Eor6 <br /> II.Type of Building(check all that apply) Lot# <br /> ® 1 or2 Family Dwelling—Number of Bedrooms 7 Subdivision Name `I <br /> Block# e� (� V0� <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> ElState Owned—Describe Use CSM Number p Village of <br /> ®Town of J w c /C J o vq <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 OnlyEOthertication to Existing System(explain) <br /> B. ❑ Permit Renewal ❑Permit Revision ❑Chan&b of Plumber ❑PennitTransfer to Newermit Number and Date Issued <br /> Before Expiration Owner <br /> IV...'''q of POWTS.S stem/Com onent/Device: (Check all that a l ) <br /> `__pH gs6urized In-Ground ❑Pressurized In-Ground ❑ At-Grade El Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> z <br /> ❑+Hpldrn�Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> VRDs'ersal/Treatment Area Information: <br /> D6ir&F1aw(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(so Dispersal Area Proposed(st) System Elevation <br /> 3oc� ti�� �i.s a y/-o <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units <br /> tQ U U U y y H N <br /> New Tanks Existing Tanks ? 2 C° <br /> a U in ti � w C7 a <br /> Septic or Holding Tank /0 G O <br /> DosingCbamber_ f <br /> VII.Responsibility.Statement-I,the undersigned,assume responsibility for installation of the PO4VTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> C,le- l��o l��ti s /� 5- s-1 ��s- fs66= yir-7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 77 D � 3S kv�5 r, W 8 5 3 <br /> VIII.County/Department Use Only <br /> Approved ❑ Disapproved Permit Fee Date Issued Issuing Agent Signature <br /> ❑Owner Given Reason for Denial � ��� I�I� 2�23 <br /> IX Conditions of Approval/Reasons for Disapproval <br /> �vl�oW r�u ccu,n►� and s-I� re�wi <br /> index a ►�.Qeds �o b,� dc�,E1d. lac l�,,r,�e sca�� on l o+ dray NOV 3 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 1 f inch s <br /> Burnett County <br /> Land Services Department <br />