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i3 Industry Services Division County <br /> l�:l_ <br /> 1400 E Washington Ave tJrNB <br /> (sl S P.O.Box 7162 <br /> Sanitary Permit Number(to be filled in by Co.) <br /> pS Madison,WI537017162 A?li 2q_z 5-9 <br /> w�witu.. <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this fort 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 <br /> u oses in accordance with the Privacy Law,s.15.04(l)(m),Stats. <br /> I. Application Information-Please Print All Information 400)( ZAZI <br /> Property Owner's Name Parcel# <br /> Lu nt rc UL Qp4aqj LLL, 0'I-018 Z-yO-ly Iy-5 05-Oo3-D(3Coo <br /> Property Owner's Mailing Address Property Location i�X ID I D <br /> 5ZI78 C r, VGovt.Lot 3 /J Ci 24-q <br /> Zip CodePhone Number y,, %,, Section f7 <br /> e �t, J 3 c1 Jq ! u Wrcle on <br /> T /O N; R�Ho� <br /> II.Type of riding(check till that apply) Lot <br /> XI or 2 Family Divclling-Number of Bedrooms Subdivision Name <br /> Block R <br /> ❑Public/Commercial-Describe Use ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> W I-1 V 102 gTovvmof SCU+-�- <br /> 111.Type of Permit: (Check only one box on Ilne A. Complete line B If applicable) <br /> A* ❑New System <br /> y lYReplacement System ❑Treatment/Holding Tank Replacement Only Other Modification to Existing System(explain) <br /> $• ❑ Permit Renewal ❑Permit Revision ❑Change of Plumber List Previous Permit Number and Date Issued <br /> Before Expiration S �hermit Transfer to New <br /> 22LO&D <br /> IV,Type of POWTS System/Component/Device: (Check all that a 1 <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) I Design Soil Application Rate(gpdso Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> VI.Tank Info Capacity in Total Q of Manufacturer <br /> Gallons Gallons Units c <br /> New Tanks Existing Tanks u b y y <br /> cu`,U in 2 -e -4 a <br /> Septic or Holding Tank 7/iLi✓ C DU <br /> Dosing Chamber <br /> VII.Responsibility Statement-1,the undersigned,assume responsib)llty for Installation of the POWTS shown on the attached plaits. <br /> Plu cr's Name(Print) Plumb i tttre�_X MP/MPRS Ntunber Business Phone Number <br /> S'-7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> l Av ,Aw I ie Wal t lebt)Ar vJ 5171069 <br /> VIII.Coun /De artment Use Only <br /> Approved ❑Disapproved Pem»t Fee Date Issued Issuing Agent Signature <br /> ❑Owner Given Reason for Denial <br /> S3 5° ro��yJ202 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> (� C�CCU C� Q <br /> �o l Low ccux,+_1 CYIJ S-Ea.-�-e V f Y u i rk_AILC rl+s �/L/ <br /> -Fa-Faik ytt4 -b he p[aud 6 l-l� -Ku lcoo CYelt�Cw h i ►u- ill <br /> Attach to complete plans for the system and submit to the County only on paper net less than S tax 11 taehes in aim <br /> Burnett County <br /> Land Services Department <br /> SBD-6398(R.08/14) 1 1tf )2 gyo <br />