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Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 <br /> NVIsconsin <br /> Madison,WI 53707—7162 Sanitary Permit Number(to be tilled in by Co.) <br /> Department of Commerce (608)266-3151 skm q-la3 -1`9 <br /> Sanitary Permit Application State Plan I-D.Number <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide 614 96 2 <br /> may be used for secondary purposes Privacy Law,sI5.04(I Xm) Project Address(if different than mailing address) <br /> I. Application Information—Please Print All Information <br /> 007 aw Qtr <br /> Property Owner's Name Parcel# Lot#ill Block#�e1 6 <br /> Property Owner's Mailing Addres Property Location <br /> 70 �'9G.1 A 1A Section Z 7 <br /> City,State Zip Code Tal <br /> hone Number <br /> kMV1kWAJ (�fN SSI6< - -To/r� cl <br /> T N, R�E o, <br /> [i.Type of Building(check all that apply) <br /> I or 2 Family Dwelling-Number of Bedrooms Z Subdivision Name CSM Number <br /> ❑Public/Commercial-Describe Use <br /> ❑State Owned-Describe Use ❑City_❑Village KTo%vnship of W j lj <br /> I1I.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. `F'NewS stem y ❑Replacement System ❑Treatment/Holding Tank Replacement Only Q 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 PDXVTS System: Check all that apply) <br /> lA Non-Pressurized In-Ground ❑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/Treat ent Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> GYM . 7 424 #Z y .Z. <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 fto Soo <br /> Aerobic Treatment Unit <br /> Dosing Chamber <br /> Vll.Responsibility Statement-I,the undersign assume responsibility for installation or the POWTS shown on the attached plans <br /> Plur ber's Name(Print) / Plumber' nature MP/N(PRS Number Business Phone Number <br /> 5 Hof/4�c�d� G�/� 85n I" 7/5 Ti= oZaZ <br /> Plumber's AddX�. <br /> City,State,Zip ode) <br /> 6 1 It /l wab /&- w • yk <br /> Vill.Coun / criartment Use Only <br /> 61�Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Datj Issu ;W �Agentnatu o tamps) <br /> Surcharge Fee) <br /> El Owner Given Reason for Denial 7 <br /> [a.Conditions of Approval/Reasons for Disapproval <br /> I <br /> APPRU"VED <br /> nn CCC0IV <br /> Attach complete plans(to the County only)for the system on paper not less than 8112 x I inches in <br /> SBD-6398 (R. 01/03) <br /> JUL 2 3 2019 <br /> Burnett County <br /> Land Services Department <br />