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County <br /> Industry Services Division e7� <br /> 1400 E Washington Ave <br /> X 9 Sanitary Permit Number(to be tilled in by Co.) - <br /> 1'1 _ P.O. Box 7162 = <br /> Madison, WI W07-7162 4 <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 POWCS 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 �g8'v I <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. ! / <br /> I. Application Information—PleasePrintAllInformation �L��/�ar� Green Wu.' <br /> Property Owner's Name Parcel# <br /> I� oro�d,�-yo-ir lat-r � ' <br /> J L'ier)cC —yva— o <br /> Property Owner's Mailing Address Property Location <br /> 13835- 114tc, 4-e uvw -TaY, tb 351DI <br /> Govt.Lot <br /> City,State Zip Code Phone Number /, Y4, Section �A <br /> N S AD (jicle one) <br /> I1.Type of Building(check all that apply) 1 Lot# T�b N; R 7J E a <br /> ❑ I or2 Family Dwelling—Number of Bedrooms Subdivision Name <br /> Block# <br /> ❑Public/Commercial.-Describe Use <br /> ❑ City of <br /> ❑State Owned—Describe Use CSM Number p Village of <br /> V- J, 51 P 3 /, Town of <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑New System p y ❑Treatment/Holding Tank Replacement Only ❑ Other Ivloditication to Existing System(explain) <br /> y �,Replacement S stem <br /> B. Permit Renewal El Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner s32Z $I/yl19-7U <br /> IV.'Tyjie.of POWTS..S stem/Con onent/Device: (Check all that app1 ) <br /> ZMos=lrres i`nzed in-Ground ❑Pressurized In-Ground ❑ At-Grade ❑ Nlound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑K lag Tank ❑Other Dispersal Component(explain) ❑Pretreatment,Device(explain) <br /> Vtl3is"ersaI/Treatment Area Information: <br /> Desrgnw(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(s fl Dispersal Area Proposed(st) System Elevation <br /> 300 , .S- 600 600 �y. y <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o <br /> New Tanks Existing Tanks <br /> C.U in ti Cn <br /> Septic or Hold ng Tank /0 4 0 �U(�0 1 r1 t` j �7,4 {d✓ X <br /> Dosing Chamber- <br /> 'Flo } 31 <br /> - - -- — — <br /> VII.Responsibility.Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number Y <br /> Plumber's Address(Sheet,City,State,Zip Code) <br /> 77G0 <br /> tEX- <br /> oun /De artment Use Only <br /> Permit Fee Date Issued Issuing Agent Signature _ <br /> roved El Disapproved _ <br /> ❑Owner Given Reason for Denial 1�25i 21 2DZy <br /> nditions of Approval/Reasons for'Disapproval J �� a�� <br /> co 4 s r- uiiY-fitu?"s D <br /> EC [E �y E <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 I/3 x 11 in s tze <br /> Burnett County <br /> sRn-F3ne (Pni i z) Land Services Department <br />