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Industry Services Division County <br /> 1400 E Washington Ave <br /> c, <br /> $p� y P.O.Box 7162 Sanitary Permit Number to be filled in by Co.) <br /> Madison,WI53701 7162 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(2),NVis.Adm.Code,submission of this fonts to the appropriate governmental unit <br /> is required prior to obtaining a sanitary permit.Note:Application foams for state-owned PO WTS 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. n I /] r /)� <br /> I, Application Information®Please Print All Information G / 10 <br /> Property Owner's Name q I_� Parcel# <br /> /0 <br /> Property Owner's Mailing Address ,�/ Property Location <br /> l e n I ►I�NL �i/V Govt.Lot <br /> City,State �J� Zip Code Phone Number , lu <br /> /•/'� 50 Z '/� /� Section <br /> /[t �etrcle one <br /> II.Type of Building(check all that apply) Lot# T_ I N; E q <br /> I or 2 Family Dwelling—Number of Bedrooms _ Subdivision Name <br /> Block# <br /> ❑Public/Commercial—Describe Use <br /> ❑City of <br /> ❑State Owned—Describe Use CSM Number ❑Village of <br /> i 1 j , n��� a Town of IClyoA) <br /> Ill.Type of Permit: (Check only one box on line A. Complete line B If applicable) <br /> A. <br /> ❑New System Replacement System ❑Treattnent/Hoiding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Re%ision List Previous Permit Number and Date Issued <br /> ❑Change of Plumber ❑Permit Transfer to New <br /> Before Expiration Oumer N\% <br /> -IV.Type of POWTS S stem/Com onent/Device: Check ail that a I <br /> ❑Nan-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade [Ytvlound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dis ersnUTreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> �D 1 /v I 306 1 1-0&1 �i.5— <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units a d$ <br /> New Tanks Existing Tanks 5 <br /> a`U in in U. 3 a <br /> Septic or Holding Tani; 7� <br /> Dosing Chamber J <br /> V1I.Responsibility Statement—J.the undersigned,assume responsibility for tallation of the POWTS shown on the attached plans. <br /> Pluu cr's Name(Pent) Plumber' ttttt MP/MPRS Ntuaber Business Phone Number <br /> Plumber's Address(Street City.State,Zip Code) <br /> Vill.Coun /De artment Use Only <br /> Approved ❑Disapproved Permit Fee Date Issued Isstt' g Agatt Si <br /> ❑Owner Given Reason for Denial lsqz6vo <br /> J-7111zo <br /> IX.Conditions of ApprovaUReasons for Disapproval <br /> Inft+ 4V Q,4aCh 0 L <br /> Fo l lbw am CCU4 -Y td s-ark (��u�r�=�� <br /> I�rD 1 lo�ct-f-fby, ;S SkU,,4A -b be Uk- 6� -F(cv W i <br /> Attach to eomplate plans for the system and submit to the County only on paper not less than S tfr x 11 Inelaw la ft, <br /> Burnett County <br /> Land Servicos Department <br /> SBD-6398(R 08/14) [12 <br />