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hidustry ces Division Cotmty 1'r <br /> 1400 E Plashington Ave <br /> ' Rd Box 7162 <br /> swz tuy Petmit Number(to he filled in Ca. <br /> by } <br /> Madison;wl 53707 7162 Iq-- <br /> Sanitary Pest Application State TransRtion <br /> //_ QN=ber <br /> In accordance with SPS M.21(2),Wis.Adm.Code,setbmission of this form to the appropriate g�overnmenW emit 6r I q 7/ <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.Peasonal information you provide may be used for shy <br /> oses in accordance with the Privacy Law s.15. 1)(mj Stats. <br /> L Application Information-Please Print AV btforamtion _l <br /> Property Owner's Name Parcel;4 <br /> C7"7U ' <br /> Property Owner's Mailing Property Location <br /> l u`' Govt.Lot <br /> City,State Zip Code Phase Number <br /> [ '�-LGIdL 1., Section <br /> 355 7 T �E lJ <br /> IL Type of Building(c N, Iz-� <br /> eek all that apply) Lot# <br /> AI or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block# <br /> 0 Public/Commercial-Describe Use <br /> 0 City of <br /> 0 State Owned-Describe Use CSM Number ❑Village of c ,A <br /> -hamV G - Town of we!q t 114a6 <br /> Ili.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> New System <br /> ys ©Replacement System ©Treatatent/Holding Tank Replacement Only ❑Other Modification to Existing system{explain} <br /> B• 0 Permit Renewal ❑Permit Revision ❑Change of Plumber 0 Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Ovmer <br /> 1V. a of POWT6 5 mlCotn neatMevice: Check all that apply) <br /> K Non-Pressurized In-Ground 0 Pressurized hi-Ground ❑At-Grade ❑Mound>24 in,of suitable soil Q Mound<24 im of suitable soil <br /> 0 Holding'Tank 0 Other Dispersal Component(explain) [ Pretreatment Device{exptaiu} <br /> V.Die ersalflYeatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate( <br /> gpdsf} Dispersal Area R uired(sf) Dispersal Proposed(st) System Elevation <br /> NT.Tan info 7Capacity in Total #of "5 <br /> WIons <br /> Manuf Curer <br /> Gallons Units c <br /> New TaksEmoting Tanks ti <br /> Sep or Hotditrg Tank !9 Q o'� <br /> ta is. <br /> nosing Chamber <br /> VIL Responsibility Statement-14 the undersigned,assume responsibility for installation of the POWTS shown on the atta ed pleas <br /> Pl berr' Name <br /> GL {Print} C�� Fiurnber's S' MP1MPRS Number Business Phone Number <br /> Plumber's Address Str City,State,Zip Code) '�� <br /> In/7C�10 a • L ,� I V� �i �? <br /> trill.Countv/1De artme se n v <br /> (Approved 0 Disapproved Permit Fee Date I sued Is gent Signature <br /> ❑Owner Given Reason for Denial • 00 2.(,e <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> AP C� <br /> V �oa5� a� <br /> P --R <br /> Attach to ooeaplcft plena for&e systom sad snbMh to tU Co"osdy on paper notless than 8 In— nn z 11 sisse <br /> JUL 2 6 2019 LU <br /> SBD-6398 UL 08/14) Burnett County <br /> Land Services Department <br />