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;zrsre�f,� County <br /> -.• *;„, Industry Services Division ,L - <br /> "' 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co <br /> P.O. Box 7162 Nb ro Z• <br /> e��.l ,�^,✓1s; Madison, WI 53707-7162 <br /> CIT Sanitary Permit A �(— <br /> pplication 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 POWTS 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 1 <br /> purposes in accordance with the Privacy Law,s.15.04(t)(m),Slats. A <br /> I. Application Information-Please Print All Information ?h o-nfi Sph 1Zol <br /> Property Owner's Name Parcel# - p <br /> /owr, F'eaha(y v7-a+d_d,tio-IS-36•S-o.s <br /> O��loO <br /> Property Owner's Mailing Address Property Location <br /> f Sit /�ed w 1'ti /eve, Govt.Lot <br /> City,State Zip Code Phone Number / �/,, Section 36 <br /> 1)6r,04,$1 /1,1 IV 3s 4 (circle one) <br /> I1.Type of Building(check all that apply) Lot# T N; R /.f` E or6P <br /> or Family Dwelling-Number of Bedrooms 3 Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Descnbe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of <br /> V Town of J 04 16SO n <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑New System Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification 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 Owner <br /> IV..Type of POWTS.S stem/Corn onent/Device: (Check all that apply) <br /> IXNoq rej.Afized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑ Iioldma Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V I)s e>sal/Treatment Area Information: <br /> Design PI&(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(so Dispersal Area Proposed(sf) System Elevation <br /> WSo S Sao CY00 93. 7 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o <br /> New Tanks Existing Tanks <br /> c U rn ti rn [z C7 w <br /> Septic or Holding Tank 1600 IGon <br /> Dosing Chamber.. GQo Gao r <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 SiWture MP/NIPRS Number Business Phone Number <br /> 1r)dS -7 4-/1s'7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 77�D AL7 .7S Gv�c�l�r� w1 <br /> VIII.County/Department Use Only <br /> ❑Approved ❑ Disapproved Permit Fee Date Issued I en gna <br /> ❑ Owner Given Reason for Denial , q <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> SEP 14 2021 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 Ill l es in size <br /> Burnett County <br /> Land Services Department <br /> SBD-6398(R0313) (%TG7 777g 3 U5 <br />