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-'''% Department of Safety County Dui-reif— <br /> ,; & Professional Services, Sanitary Permit Number(to be filled in by Co.) <br /> +5, �_ ,y' Industry Services Division SR1J�5- i37 <br /> ,, ,� cs7-15--119 W.a7!83 <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),Stats. ���� hh���� <br /> I.Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> Je c igNifi o7ey8 z4 -/6 1 3 02-000-01A= <br /> Property Owner's Mailing Address Property Location <br /> z,.4/�,l N Tax. it) 11439 <br /> 3�Q/ Z/ � Govt.Lot <br /> City,State ,,/ Zip Code/ Phone Number <br /> Nklao�81, '" 6TA/497 ' , '1<,/Section /3 <br /> II.Type of Building(check all that apply) Lot# T 3-/�A N R /b ..iv <br /> D 1 or 2 Family Dwelling-Number ofBedrooms Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> 0 City of <br /> ❑State Owned-Describe Use CSM Number 0 Village of v A <br /> �1 f 1 3 KTown of M a t_r or <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 0 In-Ground ❑At-Grade Nt Mound ❑ Individual Site Design ❑Other Type(explain) <br /> (conventional) <br /> C. ❑ Renewal Before ❑Revision ❑Change of Plumber LiTransfer to New Owner <br /> 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(sf) System Elevation <br /> y5C 1 • o Li 50 L1 50. / 95 .20 <br /> Capacity in Total I #of Manufacturer <br /> Tank Information Gallons Gallons I Units a U'$ y <br /> New Tanks Existing Tanks y c a+ p y a A <br /> & U� in . rn x0 ri, <br /> Septic or Holding Tank 1000 400 <br /> /�/� � �s�1 9'Q/ X <br /> Dosing Chamber V ($(� <br /> V.Responsibility Statement-I,the undersigned,assume responsibility for Installation of the POWTS shown on the attached plans. <br /> Pia;Name Print) Plumber' afore /�f MP/MPRS Number Business Phone Number <br /> ��To�����. ���/ t�1�� 7i5-66-ozoZ <br /> Plumber's <br /> �Address(Stree//t,City,State,Zip C)• ) <br /> 6ff <br /> VI.County/Department Use Only <br /> dif Approved ❑Disapproved Permit Fee_ Date Issued Issuing <br /> Isssuin�g�Agent <br /> t Sign J� <br /> ❑Owner Given Reason for Denial S 12 /2zJzz' ���\ u, , <br /> Conditions of Approval/Reasons for Disapproval <br /> Iu )- CO 5.040rta-S <br /> llo c p,,t.,�-{t, at, S-J-�e re7L4(ef)rnen4S `.1 1�9 <br /> w aECEiN EThn <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 t�Che la etzeJ U L 2 Z 2025 <br /> I.)) <br /> SBD-6398(R.03/22) L Burnett County <br /> Land Services Department <br />