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County <br /> Industry Services Division ��rr1�Tr <br /> -- - - - <br /> ,�� xf 1400 E Washington.Ave Sanita Permit Number to be filled in by Co.) _- <br /> 9 <br /> P.O. Box 7162PIN�2q 9.�. <br /> Madison,WI 53 70 7-71 62 <br /> State Transaction Number <br /> Sanitary Permit Application <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 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 Gl SS 3 <br /> purposes in accordance with the Privacy Law,s.15.04(I)(m),Stats. J <br /> I, Application Information—PleasePrintAllInformation %�or" -fo �Zp' CL)LIb 2 <br /> Property Owner's Name_ Parcel <br /> o-7 oil-d '16 -15 b- S <br /> o 0), Ibl� <br /> Property Owner's lvfailin Addrress Property Location <br /> ) u- Govt.Lot <br /> City,State 1 Zip Code Phone Number /, Y4, Section 3�O <br /> )Ak) �/ i/V ��35 � (circle on <br /> H.Type of Building(check all that apply) EBlock# <br /> T�Q_N; R�_E o <br /> ❑ I or Family Dwelling—Number of Bedroorns 3 �J Subdivision Name <br /> +— <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> ❑Staid Owned—Describe Use C`SIMNumber e� ❑ Village of <br /> �I�lp PZS 1 OrTownof �A.c, I- <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 Only ❑ Other Modification to Existing System(explain) <br /> B. 0 Permit Renewal ElPermit Revision ElChange of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner N v 3 <br /> IV..r'�e,of POWiT'S.S stem/Com onent/Device: (Check all that a I ) <br /> Mori=€i es razed In-Ground ❑Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑:Efo[aiir Tank ❑Other Dispersal Component(explain) ❑Pretreatment,Device(explain) <br /> V513:is`'ei sal/Treatment Area Information: <br /> Del �Ppd} Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> s 9bo 9�v q3: � <br /> VI.Tank Info Capacity in Total #of Manufacturer c <br /> Gallons Gallons Units <br /> New Tanks Existing Tanks <br /> Septic or Holding Tank b 6' lQ�a <br /> DosingCliamber- 6d0 ('OG(/ r )i <br /> V1I.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 1vIP/NIPRS Number Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) li <br /> VII1.County/Department tse Only <br /> Permit Fee Da a Issued Issuing Agent Signature <br /> Approved El Disapproved 2 2 <br /> ❑Owner Given Reason for Denial ✓ `� J . <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> 41ee f � s au/ Va-k 1 MAY 1 0 202 <br /> IlAW A.0 Cau/ Y Y��cci✓2 \ <br /> Burnett County <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 inc sins an ervices epar men <br /> QRh 41no mn-„1. - <br />