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"= Industry Services Division County ) <br /> f? 1400 E Washington Ave <br /> P.O.Box 7162s `, � nita7F4t.,N%PobefiHedinbyCo.)F Madison,W53707 162 Ra <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 38321(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit <br /> is required prior to obtaining a sanitary permit.Note:Application fortes for state-owned POINTS 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(l)(m),Stats. <br /> I. Application Information—PIease Print Al!Information 3_4D2 <br /> Property Owner's Name / Parcel# <br /> Al �Z1S ol-�l -Z�D z/-1 oz.006-011dol <br /> Property Owner's Mailing Address Property Location <br /> 08 tiZ X9 Govt.Lot <br /> City,State Zip Code Phone Number �yi f t z <br /> I .ff N /,, Section <br /> J NQ/ tN t, G�/ S I Y�o!e' rcie o <br /> H.Type of Building(check all that apply) Lot� T�N; R�E a W <br /> I or 2 family Dwelling—Number of Bedrooms Subdivision Name <br /> � <br /> Block R <br /> ❑Public/Commercial—Describe Use <br /> ❑City of <br /> ❑State Owned—Describe Use CSM Number ❑Village of 7� 1W Tol4m of S0)y <br /> 111.Type of Permit: (Check only one box on tine A. Complete line B if applicable) <br /> A. <br /> ❑New System Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: Check atl that a ! ) <br /> CrNon-Pressurized In-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 /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil A piication Rate(gpdsf) Dispersal Area Required(sfl Dispersal Area Proposed(sf) System Elevation <br /> 6C� <br /> V1.Tank Info Capacity in Total f of Manufacturer <br /> Gallons Gallons Units o g <br /> New Tanks Existing Tanlu v i U L u y a <br /> c`U a,us y rn a U a <br /> Septic or Holding Tank <br /> Dosing Chamber <br /> V1I.Responsibility Statement—I,the undersigned,assume responsibility for lastallatloa of the POWTS shown on the attached plans. <br /> Piu er's N�01­A_uv <br /> (Print) Plumber' ignat MP/MPRS Ntupber Business Phone Number <br /> / �5'!�5� 1715_-T9-020-Z <br /> Plumbrr's Address(Street,City,State,Zip Code)We/ <br /> AolA nI 1/__ W* ebolf-' t1/6 ?7 <br /> VIII.Coun /De artment Use Only <br /> Permit Fee Date Issueed7� Issuing Agent Signature <br /> ,(�Approvcd ❑Disapproved <br /> ❑Owner Given Reason for Denial S��� `il/W(X2q <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Fo l d Stu- re u/� rR <br /> v1�.ow ct,e-l. �1 �fiuw� S <br /> Attach to complete plans for the n-stem and submit to the County only on paper not less than 8 V2 z 11 inches In sim <br /> Burnett County <br /> Land Services Department <br /> SBD-6398(R 08114) <br />