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Industry Services Division <br />Count? <br />1400 E Washington Ave <br />P= ) <br />P.O. Box 7162 <br />Madison, Wl 53707-7162 <br />Sanitary Permit Number (to be filled in by Co.) <br />�' L l <br />Sanitary Permit Application <br />State Transaction Number <br />in accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental unit <br />Project Address (if different than � ailing address) <br />�tJ L <br />is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are submitted to <br />be for <br />the Department of Safety and Professional Services. Personal information you provide may used secondary <br />��4 p p � i <br />purposes in accordance with the Privacy Law, s. 15.04(1)(m), Slats. <br />r. . <br />lJC <br />I. Application Information - Please Print All Information <br />Property Owner's Name <br />Parcel # 4F' D <br />(0011,--1 15-0 0 <br />TES <br />Property Owner's Mailing Address <br />OGovt. <br />Property Location <br />t <br />��,� y,, ti +/4, Section <br />City, State <br />Zip Code Phone <br />Number <br />J <br />( <br />ram= trcle one <br />04, ��T�� /V 1 <br />O 1 <br />7 40 N; R � F or�V� <br />IT. Type of Building (check all that apply) Lot <br /># <br />Subdivision Name <br />1 or 2 Family Dwelling -Number of Bedrooms <br /># <br />Block <br />❑ City of <br />❑ Public/Commercial - Describe Use <br />❑ State Owned -Describe Use CSM <br />❑ Village of _ <br />ATown of <br />Number <br />I1I. Type of Permit: (Check only one box on line A. Complete line B if applicable) <br />A. <br />❑ New System <br />)p Replacement System <br />❑Treatment/Holding Tank Replacement Only <br />Other Modification to Existing System (explain) <br />B. <br />❑ Permit Renewal <br />❑ Permit Revision <br />❑ Change of Plumber <br />El Permit Transfer to New <br />List Previous Permit Number and Date Issued <br />Before Expiration <br />Owner <br />TV. <br />Type of POWTS S stem/Com onent/De-,ice: Check all that apply) <br />X-Non-Pressurized In -Ground ❑ Pressurized In -Ground ❑ At -Grade ❑ Mound > 24 in. o suitable soil ❑ Moun < 24 in. of suitable soil <br />❑ Holding Tank ❑ Other Dispersal Component (explain) Pretreatment Device (explain) <br />V. Dispersal/Treatment Area Information: <br />Design Flow (gpd) Design Soil Annliration Rate(gpdsf) Dispersal Area RIired (so spersal Area Proposed (so System Elevation <br />KS o 6t1/ 1 <br />VI. Tank Info i nyaa ny in Total # of anufacturer y <br />c <br />Gallons Gallons Units v <br />U � y <br />New Tanks Existing Tanks v ,� 3 a s m <br />a U in on i., c7 Cr <br />Septic or holding Tank <br />` /v p <br />Dosing Chamber <br />/ ^^ <br />VII. Responsibility Statementt-- 1, the undersigned, assume re risibility foir installation of the POWTS shown on the attached plans. <br />Plumber's Name (Print) <br />Plumber's Sig re <br />MP/MPRS Number <br />Business Phone Number <br />I &x *8 A I <br />12S3 Sri $ <br />1 <br />Plumber's Address (Street, City, State, Zip Code) <br />VIII. Count /De artment Use Only <br />Approved <br />Disapproved <br />Permit Fee <br />Date Issued <br />Issuing Agent Signature <br />El Owner Given Reason for Denial <br />S -I- <br />37 s <br />IX. Conditions of Approval/Reasons for Disapproval <br />� - C(��Sg(�l <br />Dan Burch. CCEflMC <br />D <br />■ V ail V ` ■ ♦/ Atac■to coPprtqFlijjs tt dicirva, and <br />Spooner, W1548011 <br />SBD-6398 fi' r 4# 253808 <br />11cl Inc k-ounry only on yupr.n <br />G-2 i7 <br />JUN - 6 20V U <br />Burnett County <br />Land Services Department <br />