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Department of Safety County <br /> = & Professional Services, ` <br /> _ Sanitary Permit Number(to be filled in by Co.) <br /> �= Industry Services Division N-A�_10 <br /> cIT-z(i— i "A/69 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission ofthis form to the appropriate governmental unit <br /> is required prior to obtaining a sanitary permit.Note:Application forms for state-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 "� �„r,{t L- k,< M <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. <br /> I.Application Information-Please Print All Information SygkO <br /> Property Owner's Name Parcel# --066 f6 4�-/T 23 <br /> Property Owner's Mailing Address d Property Location <br /> 5- -A� Govt.Lot <br /> City,State Zip Code Phone Number <br /> 111i „ ( r� cl e- g "ICY <br /> 7 '/<, '/<, Section <br /> II.Type of Building(check all that apply) Lot# T �O N R 6 E o <br /> A 1 or 2 Family Dwelling-Number of Bedrooms � �( ' L I- (-�) Subdivision Name <br /> Bloc # 'S < C) <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> ✓j�: P Z9 G ❑Town of-c)e -CN n 1 <br /> III.Type of POWTS Permit:(Check either"New"or"Replacement"and other applicable on line A. Check one box on line B.Complete line C I <br /> applicable.) <br /> A. ❑New System Replacement System ❑ Other Modification to Existing System(explain) ❑Additional Pretreatment Unit(explain) <br /> B' ❑ Holding Tank In-Ground ❑ At-Grade ❑ Mound ❑ Individual Site Design ❑ Other Type(explain) <br /> (conventional) <br /> C. ❑ ist Previous Permit Number and Date Issued <br /> Renewal Before ❑ Revision ❑ Change of Plumber ❑ Transfer to New Owner�1 -6vo <br /> q /`� /19Expiration ` <br /> IV.Dis ersal/Treatment Area and Tank Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpd/sf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation of <br /> Pr <br /> Capacity in Total #of Manufacturer <br /> Tank Information Gallons Gallons Units U $ v y y <br /> New Tanks Existing Tanks y p ea <br /> a ru inn y inn V. <br /> Septic or Holding Tank /S-? 0 � /S 3n l�`i a >C <br /> Dosing Chamber J <br /> V.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber' Si re MP/MPRS Number Business Phone Number <br /> Plumber's Address(Street,City, <br /> //State,Zip Code) <br /> VI.County/Department Use Only <br /> Approved ❑Disapproved Per iit]Feee Date sued Issuing Agent Signature <br /> ❑Owner Given Reason for Denial $✓ ! <br /> Conditions of Approval/Reasons for Disapproval _ <br /> �iCef aw �uiz� re .s D E C [E 0 V F <br /> Fly/lam aU COUA4,1 Oul f-YW �u0 <br /> S S-Fcm lva4-fd auf 4 - to l°�a"� SEP 2 ' 2024 <br /> y KFE 7q2 P�- <br /> Burnett Countg- <br /> Attach to complete plans for the system and submit to the County only on paper not less than S 1/2 x 11 Inc s in shard Services Department <br /> 6575 atud# 1 I Z 30 <br /> SBD-6398(R.03/22) <br />