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y�„,,As kic„,o) Industry Services Division County <br /> 4822 Madison Yards Way Bienett- <br /> 7F® `' Madison,WI 53705 Sanitary Permit Number(to be filled in by Co.) <br /> _ ) P.O.Box 7302 $Aj-, !`� <br /> Madison,WI 5302 e 7!� <br /> 't� "13iro4y� C�7/ <br /> Sanitary Permit Application <br /> State Transaction Number <br /> pp <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate govemmental'imit <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 ion5 � "I/d rt.,i <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. <br /> I.Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> ph�o.�rn uStbl`o tTi-ago-2yO-If-v+5'15-y3J-ollcoo <br /> Property Owner's Mailing Address Property Location 'faX `D 1ligli <br /> i 521 E 3 S'*h St, Govt.Lot <br /> City,State Zip Code Phone Number <br /> 1411d1hv°wpo1,5 MlJ cs- -i (o/2-- 382- 9'411 1, 1/4, Section CJY <br /> II.Type of Building(check all that apply) 3 Lot# T yd N R )la E or(� <br /> K I or 2 Family Dwelling-Number of Bedrooms q I�Su_�b1�di�vvision Name <br /> Lri f <br /> Block# l ti4YDEW LACE <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number 0 Village of <br /> .Town of Doak\Qllei <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 if <br /> applicable.) <br /> A. g 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 Cl Other Type(explain) <br /> (conventional) <br /> C. ❑ Renewal Before CIRevision CIChange of Plumber CITransfer to New Owner <br /> List Previous Permit Number and Date Issued <br /> Expiration <br /> IV.Dispersal/Treatment Area and Tank Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpd/sf) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> q5-D .-i 6at2_ tpsZ. 9y.o <br /> Capacity in Total #of Manufacturer <br /> Tank Information Gallons Gallons Units E U 'E y 2 <br /> - New Tanks Existing Tanks o ;; p S 1a U in . rn u. C7 E. <br /> Septic or Holding Tank 1 py,�� I oo ( w2.t &C x <br /> Dosing Chamber wV <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 /> Richard Hopkins 225851 715-866-4157 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 27760 Hwy 35 Webster WI 54893 <br /> VI.County/Department Use Only <br /> Approved CI Disapproved $Permit Fee Date Issued Issuing Agent Signature <br /> 0 Owner Given Reason for Denial 125 7l i'20Z5 ' 1s4,1a. A J ("tifteiet —' <br /> Conditions of Approval/Reasons for Disapproval <br /> MM,t Al St- c-s CK jai lit a5 <br /> av ads-147k re% �� I ECE IMI Th <br /> &e c u,Lt,-li cu s ( , eWAnc,c1 tocw b'N a-Ra J U N 2 3 2025 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x ll1 me in size <br /> Burnett County <br /> SBD-6398(R.02/22) - Land Services Department <br />