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•���.j, County <br /> i" r� Industry Services Division Bt.l k^0 g'� <br /> 1400 E Washington Ave <br /> 9 Sanitary Permit Number(to be tilled in by Co.) <br /> P.O. Box 7162 <br /> 4.�. r�% Madison, V`/I 53707-7162 <br /> Sanitary Permit Application StateTTr',ansa tion Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit v 1 4913 <br /> is required prior to obtaining a sanitary permit. Note:Application forms for state-owned PO WTS are submitted to Project Address(if different than mailing address) <br /> the Department of Safety and Professional Servies. Personal information you provide maybe used for secondary ��0 y y <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Slats. ��"� ' <br /> I. A lication Information-Please Print All Information 6kaw 'Df.. <br /> Property Owner's Name Parcel# 1�/S a7 ,$',5'= Cj 76 <br /> �7d <br /> oso 000 <br /> Property Owner's Mailing Address Property Location <br /> // <br /> -7d 30 3,-C# Govt.Lot <br /> City,State Zip Code Phone Number y, y, Section pf-7 <br /> S a r, 5 o i e, F/- 3 yd Y 3 (circle one <br /> I1.Type of Building(check all that apply) Lot# <br /> T 4/I N; R JS' E <br /> Y1 l or Family Dwelling-Number of Bedrooms y 0 Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use ❑ City of <br /> ❑State Owned-Describe Use <br /> CSM Number ❑ Village of <br /> Town of <br /> III.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 Ivlodittcation to Existing System(explain) <br /> B. ❑ Pennit Renewal ❑ Pen-nit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Pen-nit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> K,dn Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑ Holdmo Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dis ersal/Treatment Area Information: <br /> Dest-Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(so Dispersal Area Proposed(st) System Elevation <br /> ° 17 Y.3� Liso gS. a 9 3- � <br /> VI.Tank Info Capacity in Total #of Manufacturer y <br /> Gallons Gallons Units ;, o <br /> New Tanks Existing Tanks o y <br /> a U h c� r V a <br /> Septic or Holding Tank p y Q <br /> Dosing Chamber tv <br /> .. J-0 0 OV i <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POINTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature NIP/MPRS Number Business Phone Number <br /> I" <br /> /?, C-t O /H s /2�"""'C 76%4—el/s7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> VIII.Coun /De artment Use Only <br /> q�4pproved ❑ Disapproved Permit Fee Date[ uue q umg it Sign re <br /> ElOwner Given Reason for Denial :?:K. 00 I �t <br /> IX.Conditions of Approval/Reasons for Disapproval f/� <br /> APPROVED E ("D.; T0YIE <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 t/.x 11 inches. siz <br /> SBD-6398 (R0313) Burnett County <br /> t snd een.irnc rlanartmant <br />