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Industry Services Division County /I <br /> 1400 E Washington Ave tr <br /> P.O.Box 7162 Sanitary Permit x�(to be filled in by Co.) <br /> � ��s x• Madison,WI537d7-7162 �� Z� — l3 <br /> _ —2 -v 65($ 8 <br /> Sanitary Permit Application Stale Transaction Number <br /> in accordance with SPS 383.21(2),Witte Adm.Code,submission of this form to the appropriate governmental unit <br /> is required prior to obtaining a sanitary permit Note:Application forms for stater'owaed POWTS are submitted to Project Address(if different than mailing address) <br /> the Department of Safety and Professional Services.Personal dnf nation you provide may be used for secondary <br /> ounioses in accordance with the Privacy Law,s.15.040)(m).Stats. <br /> L Application Information—PIease Print All Information Q l ; 2 8 2- <br /> Property Owner's Name r pamd# <br /> Property Owner's Mailing Address Property Lcadon. <br /> Gaut Lot <br /> City,State Zip Code Phone Number %., Y+, Section L <br /> `9/U/�� `V f —��i 1/6 ��one <br /> A.type of Bitildin (check all war apply) ._.� Lot# <br /> T 3 F' N, R�Ci E 0�� <br /> I or 2 family'Dwolling—Number of Bedrooms Subdivision Name <br /> Block# <br /> Public/Commercial—Desciibe Use 0 City of <br /> ❑State Owned—Describe Use CSM Number ❑Village of A Torun of pOod <br /> III.Type of Permit: (Check only one box online A. Complete line B If 2ppHeabie) <br /> A. New System ❑Replacement Y eP System ❑TieatmmtlHoiding Tank Replacement Only 13 Doer Modification to FaristingSystem(explain) <br /> $. ❑Permit Renewat 0 Permit Re%ision ❑Change a0lumber 0 Permit Transfer to New list Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV,Type of POVYTS S tem/Com onent/Devlce: Check all that apply) <br /> ❑Non-Pnosurized In-Ground ❑Pressurized In.Ground ❑AI.Grade ❑Mound>24 in.of suitable soil ,Z Mond<24 in.of suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ©Pietreatmimt Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sfl D ersal Area Pr <br /> oposed ropased(sf) system Elevation <br /> z <br /> VL Tank Info Capacity in Total #of Martrifacturer <br /> Gallons Gallons Units <br /> New Tanks E3 ting Tanlm ti9 gw <br /> U y as I it t7 S. <br /> Septic or Holding rook O(7 <br /> DosingC6amber 0 <br /> VII.Res onslbltky Statement 1.the undersigned,assume respoaftift fbr h4tal)aton of the POWTS shown on the attached plans. <br /> P u er's Name(Print) Plutabds S MP/MPRS Nmpber Basincss Phone Number <br /> Plumber's Address(Street,City,State,Zip Codej <br /> t Aryl t k W tol—&- <br /> VIlL Coun eliartment Use Only <br /> Approved ❑Disapliroved Ptnr&Fee❑Owner Given Reason for Denial S q26 o_ 1Z12/7_'n_z1 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Nt W kf�h aidSfu�e r�Yu;�S JAN 2 .9 2024 <br /> W colt �,l <br /> IS-�n n o�P,l da 4o he ff,�l'WD , Dtj� I dtvUtj'1 y awed � Parcel Burnett County <br /> to tmeptde pimWr system ere!whmtt to due Cetuty G*oa PWw vast teas tbaa i to x if nacho sea r men <br /> SBD-6398(R.08114) a5�o <br />