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�oEtr�,Hr� Department of Safety County, <br /> & Professional Services, <br /> Sanitary Permit Number(to be filled in by Co.) <br /> Industry Services Division _�Z <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this 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 <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Slats. <br /> I.Application Information—Please Print All Information 32(n <br /> Property Owner's Name Parcel# <br /> 04A" LAM,061 o t <br /> Pr perty Owner's Mailing Address Property Locatio <br /> 36� Govt.Lot <br /> City,State Zip Code Phone Number <br /> ' /<, ''/e, Section <br /> 11.Ty of Buil ing(check all that apply) Lot# T N R_t&___E o <br /> I or 2 Family Dwelling—Number of Bedrooms Subdivision Name <br /> Block# <br /> ❑Public/Commercial—Describe Use <br /> ❑City of <br /> ❑State Owned—Describe Use CSM Number ❑Village of <br /> Town of 6Aba"40 <br /> 111.Type of POWTS Permit:(Check either"New"or"Replacement"and other applicable on line A. Check one box on line B.Complete line C if <br /> applicable.) <br /> A. <br /> ❑New System eplacement System El Other Modification to Existing System(explain) El Additional Pretreatment Unit(explain) <br /> B. ❑Holding Tank In-Ground ❑ At-Grade Design Type(explain) <br /> ❑Mound Individual Site Desi ❑Other T e <br /> (conventional) <br /> s NNber and Date Issued <br /> C• El Renewal Before El Revision El Change of Plumber El Transfer to New Ownerist Previou Permit p <br /> Expiration �� o Il��g' <br /> IV.Dispersal/Treatment Area and Tank Information: <br /> Desi n Flow(gpd) Design Soil A lication Rate(gpd/sf) Dispersal rea Required(sf) Dispersal Area Proposed(sf) Syste Elevation <br /> 400 6100 <br /> Capacity in Total #of Manufacturer <br /> Tank Information Gallons Gallons Units V $ <br /> New Tanks Existing Tanks c <br /> n U yr v rn W C7 P <br /> Septic or Holding Tank <br /> Dosing Chamber <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's Signature MP/MPRS Number Business Phone Number <br /> f I-IfIvy 04 452z�gS� r� Jb ,S <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 7 b 1 <br /> VI.County/Department fse Only <br /> Permit Fee Date Issued Issuing Agent Signature <br /> Approved El Disapproved <br /> S <br /> ❑Owner Given Reason for Denial <br /> Conditions of Approval/Reasons for Disapproval <br /> u o- WA sekl�ac k s C O MY E <br /> �6llU' au c rnd S-I-a.-�c red ui Ire.�,,�+5 <br /> a�✓t-h-� <br /> xksi4�j Sys-fie M -b be evrop ' a10u"�'d. MAY U 7 2025 <br /> Burnett County <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 ches aqd Services Deparm, <br /> SBD-6398(R.03/22) <br />