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Industry Services Dtvtstt)ri <br />1400 E Washington Ave <br />County <br />go <br />%y r <br />PA Box 7162 <br />Madison, WI 53707=7152 <br />Sanitary Pamit Nurnbw (to be filled is by Co. <br />R�1 < ►ri-1 4 /q 9 Z <br />-t o <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 />I ---- <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 Privacy Law, s. i 5. i mA Stats. <br />1. A In <br />Application Information - Please Print All formation <br />Property Owner's Name <br />/i'/� <br />Parcel # <br />dFOO <br />—Q <br />Property Owner's Mailing Address <br />44- <br />Property Nation <br />Zi <br />Govt. Lot <br />S t/., Section 4 - <br />-4 <br />City, State ZAP Code <br />Phode Number <br />W vi/ 5 y8 t <br />H. Type Building <br />_ <br />- SG <br />T -79 N, R E <br />of (check all that apply) <br />Lot # <br />Subdivision Name <br />AI or 2 Family Dwelling - Number of Bedrooms <br />D Public/Commercial - Describe Use <br />Block # <br />❑ City of <br />❑ State Owned - Describe Use <br />❑ Village of <br />C' SM)Number <br />/ <br />�" / G 170 <br />j <br />Town off F['1 /1[� <br />M. <br />Type of Permit: (Check only one box on line A. Complete line B if applicable) <br />A. <br />❑ New System <br />Replacement System <br />❑ Treatment/Holding Tank Replacement Only <br />❑ Other Modification to ExistingSystem (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. T e of POWTS S stem/Com nent/Device: Check all that apply) <br />Non -Pressurized in -Ground ❑ Pressurized In -Ground ❑ At -Grade ❑ Mound > 24 im of suitable soil <br />❑ Mound < 24 in. of suitable soil <br />D Holding Tank D Other Dispersal Component (explain) ❑ Pretreatment Device (explain) <br />V. Dis ersalffreatment Area Information: <br />Design Flow (gpd) <br />® <br />Design Soil Application Rate(gpdst) <br />Dispersal Area Required (sf) <br />Dispersal Area Proposed (sf) <br />System Elevation <br />VI. Tank Info <br />Capacity in <br />Gallons <br />Total <br />Gallons <br /># of <br />Units <br />Manufacturer <br />� <br />� <br />v v� <br />Now Tmrks <br />Exist�g Tanks <br />Septic or Holding Tank <br />Dosing Chmnber <br />r <br />�. <br />VII. Responsibility Statement- 1, the undersigned, assume responsibility for installation of the POWTS shown <br />on the attached plans. <br />Pl ber's Name (Print) Plumber's ature MP/MPRS Number Business Phone Number <br />t <br />Plumber's Address sfree, City, State, ip Code) <br />VM. Coun /De artm e i <br />PproVed ❑ Disapproved Permit Fee Date Issued Issuing Agent Signature <br />� <br />❑ Owner Given Reason for Denial _3 %s6 <br />IX. Conditions of Approval/Reasons for Disapproval <br />C C�LE0MC <br />Attach to complete plans for the sy n sub o only on paper not tm than & <br />hes in size <br />� <br />SBD-6398 (R. 08/14) <br />Burnett CountyLand <br />Services Department <br />