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Industry Senices Division County <br /> ® �;i� 1400 E Washington Ave UlN <br /> P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> 1 S Madison,WI 53707-7162 7 <br /> �.`-- <br /> �tYf(t14,.' <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 forts 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 /> 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 /> �tatiP JG�7I='�/ � o7•o�Z-Z-yizJs-l2�lS-��/OyA�b <br /> Property Owner's Mailing Address Property Location A_ <br /> I p <br /> Govt.Lot <br /> City,State , / Zip Code Phone Number /,, %,, Section Z <br /> / l & �`v `JS�Zy ��JJ ctrcieon <br /> T !� N. R/6E <br /> II.Type of Building(check all that apply) 2, Lot <br /> %I or 2 Family Dwelling—Number of Bedrooms / �`� Subdivision Name <br /> Blockrr 1D-M VV <br /> ❑Public/Commercial—Describe Use ❑City of <br /> ❑State Owned—Describe Use CSM Number ❑Village of <br /> To�szt of �QC�ro�J <br /> 111.Type of Permit: (Check only one boa on line A. Complete line B If applicable) <br /> A' (XNew System <br /> y ❑ Replacement System ❑TreatmentJHolding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> $• ❑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 all that appi <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(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> y . S 9ft� q32 <br /> VI.Tank Info Capacity in Total <of Manufacturer <br /> Gallons Gallons Units o <br /> New Tanks Existing Tanis <br /> 0 2 u a <br /> a a <br /> a U in �, rn i.L t7 a <br /> Septic or Holding Tank D !ODv w <br /> Dosing Chamber V <br /> VII.Responsibility Statement-L the undersigned,assume responsibility for Installation of the POWTS shown on the attached plans. <br /> Plu cr's Namc(Print) / Plumber's Sign MPJMPRS Number Business Phone Number <br /> Piumhrr's Address(Street,City,State,Zip Code)W01 <br /> f /7"V01/7 r4 1 I-' (Ajebe274er V,- 5L1409 <br /> VIII.Coun /De artment Use Only <br /> Approved ❑Disapproved Permit Fee Date Issued IssuingIssuing Agent Si rune <br /> ❑Owner Given Reason for Denial S /�5 � g I 5 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> _-� Q,(�. �-�K CLJ s <br /> Taw � cou,n�y acd S-fa'k re�cc! fs <br /> n�ma�,� {� dP,�r'rce of i nS�ec <br /> Attach to complete plans for the system and submit to the County only on paper not Ins than 8 iR 111 Inches In <br /> MAR 24 2 21 <br /> SBD-6398(R.09/14) Burnett County <br /> Land Services Department <br />