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County <br /> Industry Services Divisionu►"n P <br /> - --- <br /> 1400 E Washington Ave Sanitary Permit Number(to beailled irt.by Co.) <br /> y� <br /> P.O. Box 7162F <br /> 4g' ! Madison, WI 53707-7162 <br /> State Transaction Number <br /> Sanitary Permit Application <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,subinission of this form to the appropriate governmental unit <br /> is,required prior to obtaining a sanitary permit. Note:Application forms for state-owned POWfS 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 ��X �D- �(e�i <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. C)U_e r I A h <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# S- S <br /> v-r-olJ��"yO-IS-,13- /S- h0 <br /> AdeAYM 1ao �{ a o4sdoo <br /> Property Owner's Mailing Address Property Location <br /> `tFI L•1,,C 1, .5 tiW Govt.Lot <br /> City,State Zip Code Phone Number /, %, Section of J <br /> mA /e- 4 A/C,t L i,7- �,�j�8 (circle one <br /> II.Type of Building(check all that apply) Lot# T y0 N; R /� E otf <br /> tp I or Family Dwelling-Number of Bedrooms 3 3s Subdivision Name <br /> Block# <br /> ❑Public/Commercial.-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number p Village of <br /> Town of .�d c Lase <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 /> a <br /> B. El Permit Renew <br /> l ❑Permit Revision El Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration ' Owner <br /> IW i``'e.of POW'ITS,S stem/Com onent(Device: (Check all that apply) <br /> Non r!razed in-Ground ❑Pressurized[a.-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> El €fo[ama Tank ❑Other Dispersal Component(explain) El Pretreatment Device(explain) <br /> aI/Treatment Area Information: <br /> Des gn `hoiv(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(st) Dispersal Area Proposed(st) System Elevation <br /> S" 900 9 00 95,�1 9y. 7 9Y, d <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o <br /> New Tanks Existing Tanks <br /> c U m ; <br /> Septic or Holding Tank <br /> /o G� �d`0 / h F1/�rn7rcv . <br /> Dosing Chamber <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 IvIPMIPRS Number Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) 4 <br /> VIII.Coun /De artment Use Only <br /> Approved ❑Disapproved Perm- <br /> itt Fee Date Issued Issuing Agent Signature _ <br /> ❑Owner Given Reason for Denial $ 335 5 7 202[f�1 � �' <br /> IX Conditions of Approval/Reasons for Disapproval n <br /> m?of OU ytfbuas v <br /> rollow Cou Y o1� s ( ✓e�ui,-�,� s M'AY '0 2 2024 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 112 s 11 in Wins ze <br /> Burnett County <br /> Land Services Department <br /> con -,in. .41Sh 4�_ LnLh_" <br />