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Industry Services Division County � �/� <br /> 1400 E Washington Ave V�/ <br /> P.O.Box 7162 Sanitary Permit Nu e_Ito be filled in by Co.) <br /> ` s Madison,WI53707 7162 j <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.2I(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 trailing address) <br /> the Department of Safety and Professional Services.Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s.15.04(I)(m,Stats. <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> 100' Tq p lQle 3 <br /> Property Owner's Mailing Address Property Location <br /> r� Govt.Lot <br /> City,State Zip Cod Phone Number Y+ Y" Section 1, <br /> AIJ4 ., 54183111 role oa <br /> II.Type of Building(check all that apply) Lot� �� <br /> T 1D N, R�Eow <br /> I or 2 Family Dwelling-Number of Bedrooms�2^ Subdivision Name <br /> Block 9 <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of _^ <br /> Town of Tcteksao4 <br /> Ill.Type of Permit: (Check only one box on line A. Complete line B If applicable) <br /> A' ❑New System R lacement System <br /> Y cP ys ❑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 3 3 26-7 cl/2-12tq <br /> IV.Type of POWTS S stem/Com onent/Device: (Check all that apply) <br /> Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑Mound 2!24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑Holding Tank 0 Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) I Design Soil Application Rate(gpdsf) Dispersal Area Required(s0 Dispersal Area Proposed(sf) System Elevatio <br /> VI.Tank Info Capacity in Total *of Manufacturer <br /> Gallons Gallons Units <br /> New Tanks Existing Tanks v a u <br /> C,U iA <br /> Septic or Holding Tani; <br /> Closing Charmer v Vv <br /> V11.Responsibility Statement-I,the undersigned,assume responsibility foS lastallation of the POWTS shown on the attached plans. <br /> Pluu cr's Name((Print) Plumber's ttttc MP/MPRS Number Business Phone Number <br /> P <br /> Plumber's Address(Street,City,State,Zip Code) <br /> .891 %voAw I J-e Wal (AJebg1-,4_,r- V1• 5t189 <br /> VIII.County/Department Use Only <br /> 9 Approved ❑Disapproved Permit Fee 'Date Issued Issuing Agent Signature <br /> $ <br /> ❑Owner Given Reason for Denial <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Ris+iti S Skm 4o be Ptyeety abvw4q<1 nD , I <br /> Attacb to complete plans for the system and submit to the County only on paper not less tlmn 8 112 x 11 <br /> UJ U N 1 u 2024 <br /> Burnett County <br /> SBD-6398(R.08114) Land Services Department <br />