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- <br />Industry Services Division <br />1400 E !Washington <br />County y <br />f' t <br />Ave <br />�'Ile <br />If <br />7 ' <br />P.O. Box 7162 <br />Sanitary Pwmit I weber (io be filed in by Co.) <br />Madison, W153707-7162 <br />lo <br />Sanitary Permit Application <br />State Transaction Number <br />In accordance with SPS 383.21(2), Win. 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 <br />the Department of Safety and Professional Services. Personal information you provide may be used for secondary <br />Project Address (if different than mailing address) <br />purposes in accordance with the PrivacyLaw, s. 15. m I Slats. <br />/ �� <br />(� <br />I. Application Information Please <br />— Print All Information <br />t/ <br />Property owner's Nam <br />G <br />Parcel # (� ..11 <br />j �© <br />Property Owners ins Address (� <br />a r <br />Pro Lotairon <br />I told � J) I <br />Lot <br />'7r, ,/+ Section <br />City, State <br />ZiP <br />Pboae Number <br />PC/-y <br />j <br />- <br />_ 1 . <br />(circle one <br />T N, R E o 4ti <br />II. Type of klieg {check a that apply) <br />Lot # <br />Xi or 2 Family Dwelling — Number of Bedrooms <br />Subdivision Name <br />❑ Public/Commercial — Describe Use <br />Block # <br />❑ City of <br />❑ State Owned — Describe Use <br />❑ Village of <br />CSM Number <br />Town of _e—, fd K%-14d <br />III. Type of Permit: (Check only one box on line A. Complete line 4 if applicable) <br />A. <br />New System <br />ys <br />� Replacement System <br />©Treatment/liolding Tank Replacement Only <br />❑Other Modification to Existing System (explain) <br />B. <br />❑ Permit Renewal <br />❑ Permit Revision <br />❑ Change of Plumber <br />❑ Permit Transfer to New <br />List Previous Permit Number and Date Issued <br />Before Expiration <br />Owner <br />IV. Type of P®WTS System/Component/Device: Cheek all that apply) <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 Q Other Dispersal Component (explain) 0 Pretreatment Device {explain) <br />V. Dis ersaVrreatrnent Area Information: <br />Design Floyal (gpd) Design Soil Application Rate(gpdsf} Dispersa�Area Required (sf j DisPe al Area Proposed (st) S stem Elevation <br />5� <br />Ij-� L <br />�� <br />< <br />VI. Tank Info Capacity in Total # of Man <br />Gallons Gallons Units °' d <br />New Tanks Rxistmg Tanks chi U �o <br />ajU viz rot t3, C7 P, <br />Septic or Holding Tank <br />Ica <br />Dosing Chamber <br />VI Responsibility Statement- I, the undersigned, assume responsibility for Installation of the P®WTS shown on the attached plans. <br />Plumber's Name (Print) Pl ign MP/MPRS Number Business phone Number <br />I Cle ........... <br />�8 )G� - <br />Plumber's Address (Street, City, State, Zip Cade) <br />W ��t a { L �� w► S <br />VIII. Conn /De artme I <br />Approved 13 Disapproved Permit Fee Date Issued Issuing A ent Signature <br />$3 <br />❑ Owner Given Reason for Denial �� t~� <br />IX. Conditions of Approval/Reasons for Disapproval <br />L5015F V E, n <br />D <br />Attach to emplete plans for the SySQsubmit to the Cou only paper notiess than 8 v1 a i t i <br />SBD-6398 (R. 08/14) �p -� Sr Burnett County <br />�. Land Services Department <br />