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CountyI� <br /> Industry Services Division U�trvt-e f4- <br /> �: -- -- - <br /> - ,rrf f sf R :,' a 1400 E Washington Ave - Sanitary Permit Number(to be tilled in-by Co.)- <br /> P.O. Box 7162 <br /> Madison, WI H707-7162 <br /> Q <br /> State Transaction Number <br /> Sanitary Permit Application <br /> In accordance with SPS 383.21(2),Wis,Adm.Code,submission of this form to thz.appropriate govermnental 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 Servies. Personal information you provide maybe used for s —d <br /> econdary <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. <br /> I. A licationTnformation—PleasePrintA.HInformation <br /> Property Owner's Name oPaa cel#�-,H0 _IS_et�_� 0,, 6,00 <br /> vakl <br /> Property Owner's Mailing Address Property Location lax .`D : 33U ZZ <br /> 4S IN Govt.Lot <br /> City,State Zip Code Phone Number y , <br /> �y�9� /+, Section d 7 <br /> W�6sf�r � 7,_ d (circle one) <br /> II.Type of Building(check all that apply) Lot# T G/ N; R E o& <br /> ❑ l or Family Dwelling—Number of Bedrooms Subdivision Name <br /> B lock# <br /> Public/Commercial-Describe Use r ev't lq#-ll <br /> ❑ City of <br /> ❑State Owned Describe Use CSNI Number p Village of <br /> NT <br /> own of Jtc 5e►� <br /> IIi.Type of Perinit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> ❑New System KReplacement System ❑Treatment/Holding Tank Replacement Only ❑Other Nloditication to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner1 . <br /> IV.'-[`'e.aPOWTS.S stemICom orient/Device: (Check all that a 1 ) <br /> Non Prey iized In-Ground ❑Pressurized In-Ground ❑ At-Grade ElMound>24 in.of suitable soil El Mound<24 in.of suitable soil <br /> i�.» — <br /> r <br /> ❑€falaur�:Tarik ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> W.D s':'ensal/Treatm eat Area Information: " }. <br /> Design Ftoiv(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Re uired(st) Dispersal Area Proposed(st) System Elevation <br /> VI.'Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o <br /> New Tanks ExisdngTanks o 2 <br /> a U in ti w ij a <br /> i <br /> Septic or Holding Tank G ly U gy U <br /> Dosing Chamber- !00 fpU f }r <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the PO'VYrS shown on the attached plans. <br /> Plumber's Name(Print) Pluumbe�r's Signature MP/MPRS Number Business Phone Number <br /> pie 16 /yG /Gln 1Gut.6+✓+✓` J.A J 9S�/ 7�'�lf yi3 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> ,1 \ <br /> w 3�5_ Z,!T_ .511 eS3 <br /> V I.County/Department Use Only <br /> Pe <br /> ,Approved ❑Disapproved urmfit Fee 2Date[Qss ed [ssuino Agent Sigriaturz <br /> ElOwner Given Reason for Denial I v`� `�{�(1'2021LU <br /> IX.Conditions of Approval/Reasons for'Disapproval <br /> Vf,� au ;t*P&S CCU <br /> Fohw V-,t mm-1`j a?I j4iok re MAR 13 2024 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 t!:s 11 C es' ize <br /> Burnett County <br /> Land Services Department <br /> 4Rn_F1ge(Pni i i) <br />