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Industry Services Division County <br /> 1400 E Washington Ave or <br /> 61 <br /> OYr• <br /> P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> Madison,WI 53707 7162A. <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 3831I(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit <br /> is mnuired prior to obtaining a sanitary permit Note:Application forts Vr state-,~t ned 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),Stars. _ <br /> I. Application Information—Please Print All Information <br /> Property Owner's Name Parcel# <br /> he � A a�-o32-Z-y,��S2fl-z � -a�-o►3dx� <br /> Property Owner's Mailing Address Property Location <br /> Z1,` Govt.Lot <br /> City,State Zip Code Phone Number S W '/A, t �g/�w/�, Section <br /> an)� �t 61Y83D errcleone <br /> �t/� T '7 N; R�E o� <br /> II.Type of Bull ng(check all that apply) Lot# <br /> 1 or 2 Family Dwelling—Number of Bedrooms Subdivision Name <br /> Block T <br /> ❑Public/Commercial—Describe Use <br /> ❑City of <br /> ❑State Owned—Describe Use CSM Number ❑Village of <br /> B Town of 4U)f h� <br /> 111.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' ❑New System <br /> y ❑ Replacement System 5[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 S stem/Com onent(Device: (Check all that apply) <br /> ❑Non-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 Application Rate(gpdso Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> VI.Tank Info Capacity in Total ff of Manufacturer <br /> Gallons Gallons Units <br /> New Tanks Existing Tanks <br /> c.U in w rn is {7 i% <br /> Septic or Holding Tank A16 f J <br /> Dosing Chamber <br /> VI1.Responsibility Statement—L the undersigned,assume responsibility for lastallation of the POWTS shown on the attached plans. <br /> Plu s Name(Print) Plumb turF, MP/MPRS Nttgtber Business Phone Number <br /> c_� * <br /> _Z <br /> Plumber's Address(Street,City,State,Zip Code),%/ ( t <br /> VIIL CounlylDepartment Use Only <br /> Permit Fee Date Issued Issuing Agent Signature <br /> �Approved ❑Disapproved `�, ," <br /> ❑Owner Given Reason for Denial <br /> IX,Conditions of Approval/Reasons for Disapproval <br /> /w4 of S,e-baciS <br /> jC�x is+hny -dunk_ -t lk &balidoJ <br /> J <br /> h,s aLml ib 4or -(fie. -lax,k replace,rvtQ 4 orl <br /> Attach to complete plans for the s)stcm and submit to the Caorn arty or papa rat 1w than 3 tax 11 todw is stm <br /> Sots bo�t� fi CCU 2r� <br /> SBD-6398(R.08114) Burnett County <br /> Land Services Department <br />