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Iy. ,r`.i},� industry services IMviston county <br /> ' 4822 Madison Yards Way BC+r/lef74 <br /> Ir"`,' , i='' Madison,WI 53705 <br /> � ti $ � Sanitary Permit Number(to be filled in by Co.) <br /> ,r ` i I P.O. Box 7302 <br /> ,- 0' Madison,WI 5302 <br /> rslroNN-i <br /> esr-a> -vs U.97 178. <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 jinit <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),Stats. <br /> I.Application Information-Please Print All Information —ay., i p 35 y 2 i <br /> Property Owner's Name Parcel# <br /> 3e55_ 3eo SOY'1 O7-032-2 yl-l(40-2iol-oil-000-ol►-0a) <br /> Property Owner's Mailing Address "� Property Location <br /> dd <br /> a2_57 /-1 1 cecvd. 4JCkY1n R c\ Govt.Lot <br /> City,T State Zip Code Phone7 Number <br /> 1Doon bu.cv L �- <br /> ( SHS JQ ,3-2-'42Z-27S/ II ,A,, /<, Section 2-.(o <br /> II <br /> II.Type of Building(check all that apply) Lot# T "l I N R__i_____E orZE) <br /> K 1 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 Town of J` <br /> (,U 1 55 <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. .,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. U .Renewal Before ❑ Revision ❑ Change of Plumber ❑ Transfer to New Owner 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(st) Dispersal Area Proposed(Si) System Elevation <br /> )00r m1 LI2 A 4 n�� 91..1 <br /> Capacity in Total #of Manufacturer <br /> Tank Information Gallons Gallons Units 1, ° o v u <br /> U v a> m N <br /> New Tanks Existing Tanks I, o v p y' ro R 0 <br /> c U in N cn iZ C7 a.. <br /> Septic or Holding Tank I DOC_a i 0,D 1 r ; C ec `y�' <br /> Dosing Chamber ( �Lj J 1 <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 A.L., <br /> 14 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 /> YA1 Approved ❑Disapproved PermitFee Date Issued <br /> n Issuing Agent Sign re <br /> 0 Owner Given Reason for Denial $ rL J ,! 7/Gt/Z� ' 16/11/60 <br /> Conditions of Approval/Reasons for Disapproval <br /> fU 0 cowitt od c&4 rertA"me 1/-s 11ECEOVET <br /> JUL 16 2025 j <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x Win size <br /> Burnett County <br /> SBD-6398(R. 02/22) Land Services Department <br />