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Department of Safety County <br /> & Professional Services, Sanitary Permit Number(to be filled in by Co.) <br /> Industry Services Division a-J� .73 <br /> Y b <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 POWTS are submitted to Project Address(if different than mailing 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(1)(m),Stats. `` C"45L", <br /> I.Application Information-Please Print All Information �3 7 T �'�"`' y Yn <br /> Property Owner's Name Parcel# <br /> Property Owner's Mailing Address p Property Location Tax l 7�3� <br /> e !j f c c l PO 'l ox+I Govt.Lot� J <br /> City,State Zip Code Phone Number <br /> r VN !�"J 5-0O3., S0 7 `7Q 5Y 4Y Al l= /,, �/<, section 5 3Z, <br /> II.Type of Building(check all that apply) Lot# T ' N R E or <br /> &rl or 2 Family Dwelling-Number of Bedrooms 3 q Subdivision Name <br /> Block# C 5 t 3'1 IT 5-ZO-7 ✓,J, Z° �u .Z� <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use i CCU Number ❑Village of <br /> ❑Town of �nrSQ.X"', <br /> III.Type of POWTS Permit:(Check either"New"or"Replacement'and other applicable on line A. Check one box on line B.Complete line Cis <br /> applicable.) <br /> A- RON-ew System ❑ Replacement System g y (explain) ❑ Additional Pretreatment Unit(explain) <br /> ❑Other Modification to Existing System (ex lain <br /> B' ❑ Holding Tank VIn-Ground ❑ At-Grade ❑Mound ❑ Individual Site Design ❑Other Type(explain) <br /> (conventional) <br /> C. ❑ Renewal Before ❑ Revision ❑ Change of Plumber ❑ Transfer to New Owner ist Previous Permit Number and Date Issued <br /> Expiration <br /> IV.Dispersal/Treatment Area and Tank Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpd/sf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> Capacity in Total #of Manufacturer V <br /> Tank Information Gallons Gallons Units 2 U B <br /> New Tanks Existing Tanks a ;; 0 <br /> U <br /> Septic or Holding Tank /aG� dp0 r <br /> Dosing Chamber <br /> V.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 <br /> L-v c. l .o. /v 37 341V YrQ 3'01 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> -3 3 0 54r)A, I A Ly 7,::),5-) <br /> VI.County/Department Use Only <br /> Permit Fee Da Issued Issuing Agent Signature: <br /> Approved ❑Disapproved❑Owner Given Reason for Denial $ ✓� � �Zy <br /> Conditions of Approval/Reasons for Disapproval <br /> a,u cc 4Af ald 1 E'0 F <br /> �' U�d -to br vn-titd al S,h�� nil JUL 2 4 2024 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 a 11 in es in <br /> Burnett County <br /> SBD-6398(R.03/22) Land Services Department <br />