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Safety and Buildings Division County <br /> ` 201 W.Washington Ave..P.O.Box 7162 -10 rut <br /> Madison,Wl 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> cOns,n <br /> Department of Commerce (608)266 3151 -i - v, 9- <br /> Sanitary Permit Application State Plan I.D.Number <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide &I4 J V� <br /> may be used for secondary purposes Privacy Law,s 15.04(1)(m) Project Address(if different than mailing address) <br /> 1. Application Information-Please Print All Information <br /> Pro erty Owner's Name Par 19 Lot 4 Block# <br /> h <br /> Property Owner ailing Address f Property Location r— <br /> S� '/<,-�C '/,, Section 1 <br /> City,State Zip Code Phone Number <br /> f/- r ��/ H <br /> (,lf C� l"� Lc.j I Z 32 lr'`.3� 1 T 3"! N R E o <br /> 11.Type of Building(check all that apply) <br /> Subdivision Name CSM Number <br /> J4 I or 2 Family Dwelling-Number of Bedrooms <br /> ❑Public/Commercial-Describe Use <br /> ❑State Owned-Describe Use ❑City_❑Village®Township of 1?441 Zee 'Q. <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A ❑New System Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IV.Type of POWTS System: Check all that apply) <br /> ❑Non-Pressurized In-Ground 19 Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil ❑ At-Grade ❑ Single Pass Sand Filter ❑ <br /> Constructed Wetland ❑ Pressurized In-Ground ❑ Holding Tank ❑Peat Filter ❑ Aerobic Treatment Unit ❑Recirculating Sand Filter ❑ <br /> Recirculating Synthetic Media Filter ❑Leaching Chamber ❑Drip Line ❑Gravel-less Pipe ❑Other(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> 41 r vsa VI-M I 9. .ao <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Units Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks <br /> Septic or Holding Tank <br /> Aerobic Treatment Unit <br /> Dosing Chamber <br /> Vll.Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plum 's Name(Print) Plum Signa a MP/MPRS Number Business Phone Number <br /> Plumber's Address(Street.City,State,Zip Code) <br /> VI11.County/ e artment Use Only <br /> Approved El Disapproved Sanitary Permit Fee(includes Groundwater Date Issued u g Agnatur St mps) <br /> Surcharge Fee) Q <br /> ❑Owner Given Reason for Denial O <br /> 1X.Conditions of Approval/Reasons for Disapproval <br /> Q1 _ 63(,q <br /> APPROVED � G 0 CE 0 M rE <br /> Attach complete plans(to the County only)for the system on paper not less than 81/2 x I 1 inches in sE AUG O 7 2019 <br /> SBD-6398 (R. 01/03) Burnett County <br /> Land Services Department <br />