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Industry Services Division County Q <br /> 1400 E Washington Ave <br /> P.O.Box 7162 �SmtaTy Permit Number(to be filled in by Co.) <br /> g Madison,WI 53707-7162 � /3,S G <br /> 0 <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 stale-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. a I. A lication Information—Please Print All Information4- he <br /> t100 <br /> Property Owner's Name // Parcel 467--pYO Z <br /> Za.c. k C)V-000 G/100/ O[/q <br /> Property Owner's Mailing Address Property Location Tax D <br /> Govt.Lot <br /> City.State Zip code Phone Number y, /., Section 3 <br /> 0 93.3 crrcle one <br /> TN; REV <br /> ^•••• r D..'.ding(ch 6 ❑ti.at �..% T.,r 4! <br /> yN�,va uui.wus tau C,.au uaa aN�ay/ <br /> lei or 2 Family Dwelling—Number of Bedrooms 3 Subdivision Name <br /> Block# <br /> ❑Public/Commercial—Describe Use <br /> ❑City of <br /> ❑State Owned—Describe Use CSM Number ❑ Village oft1 <br /> Town of W• GI/L�S�J�( <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> ❑Treatment/Holding Tank Replacement On ❑Other Modification to Existing System(explain) <br /> ❑New System Replacement System g p n� g }' (.p <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber Permit Transfer to New List Previous Permit Number an Date Issued <br /> ❑ �m <br /> Betore i4,xpiration Uwner SA-K-Z' -31 I l W`1 <br /> IV.Type of POWTS System/Component/Device: Check all that apply) <br /> �L <br /> ❑ Non-Pressurized hi-Ground ❑Pressurized In-Ground ❑At-Grade ❑Mound>24 in.of suitable soil Mound<24 in.of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> e _... ' meDnwtr�a. 'n^for'mationn: <br /> a ..�___a �_ ri 1 n n._ ., a <br /> in I o._.. . <br /> .,y S, au,.,I'; ,..,.. <br /> �� �• � �t� �J� IOD. / 7 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units !jQ p c 7„ <br /> New Tanks Existing Tanks <br /> Holding Tank Z ` <br /> W <br /> Do r ber <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> P ber's Name(Print) Plumber's Signature MP S Number Business Phone Number <br /> "A,£ -��,�.,k; s 2,L -S� CIS" �QI -,�3f3 <br /> PI ber' Address(Street,Citv.State,Zip Code) <br /> VVIII.County/ e artment Use Only <br /> IJp Approved ❑Disapproved Permit F.eeeee tD^ate Issuedf��(� Issuing Agent Signature <br /> ❑Owner Given Reason for Denial $ I�tJ� "''_I / <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> ffl ffif V kyqa'dS J �4�� <br /> 0110w c�,4 ad Sot fie re?u/ >°0QW2' F) CE C C ME <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 U n hes in size <br /> JUN 17 2CE 4 <br /> Burnett County <br /> SBD-6399(R.08/14) Land Services Department <br />