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,- a <br /> County <br /> Industry Services Division (3t�t rh lE"# <br /> 1400 E Washington Ave Sanitary Permit Number(to be tilled in by Co.) <br /> P.O. Box 7162 � let 4 ,yr, Madison, WI 53707-7162 cc -7 <br /> 7� <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit _P1 4ll951 <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 Servies. Personal information you provide may be used for secondary .1 <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Slats.I. A - <br /> lication Information—Please Print All Information e i f Oe t v 2 <br /> Property Owner's Name Parcel# -IV- 70S-O O S" <br /> Property Owner's Mailing Address Property Location <br /> Gl-73 Ci f" Govt.Lot <br /> City,State Zip Code Phone Number y,, /,, Section � <br /> webS�GY 1'✓il"', S1451U T yo N; R � (circleoon`l% <br /> 11.Type of Building(check all that apply) Lot# <br /> l or 2 Family Dwelling—Number of Bedrooms Subdivision Name <br /> Block# <br /> ❑Public/Commercial—Describe Use ❑ City of <br /> ❑State Owned—Describe Use <br /> CSNI Number ❑ Village of <br /> Town of 04E 44 <br /> II1.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> ❑ New System Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑ Pennit Renewal ❑Permit Revision ❑Change of Plumber 70-ne, <br /> it Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> ,Y Non Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑ Flaldma,Tank ❑Other Dispersal Component(explain) El Pretreahnent Device(explain) <br /> V I)is ersLi Treatment Area Information: <br /> Des[,, Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(so Dispersal Area Proposed(st) System Elevation <br /> Sop r 7 y�9 600 9a.a l 7 g3 <br /> V1.Tank Info Capacity in Total #of Manufacturer y <br /> Gallons Gallons Units o <br /> New Tanks Existing Tanks � y N N <br /> 4 o Y E y = co <br /> n U rn cL U n <br /> Septic or Holding Tank <br /> Dosing Chamber <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature NIP/MPRS Number Business Phone Number <br /> /?.e,le flo &,h s lei 4 �?o�S'8-s/ <br /> Plumber's Address(Street,City,State,Zip Code) <br /> J 7 7 O . 3S <br /> VIII.Coun / )e artment Use Only <br /> pproved ❑ Disapproved Permit Fee Date Inssued Is ing Agent Si ature <br /> ❑ Owner Given Reason for Denial $ 3?'" ' q �`�j�I� ` <br /> IX.Conditions of Approval/Reasons for Disapproval D <br /> APPROVEMS <br /> JUL 2 2 2019 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 inch in size <br /> Burnett County <br /> Land Services Department <br /> SBD-6398(R0313) <br />