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ticnxrN, County <br /> Gam', Industry Services Division <br /> 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> P.O. Box 7162 <br /> r ti-f' Madison,WI 53707-7162 -Ia 4p <br /> r tip: <br /> Sanitary Permit Application State Transaction pNumber <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit <br /> is required prior to obtaining a sanitary permit. Note:Application forms for state-owned POWTS are submitted to <br /> the Department of Safety and Professional Services. Personal information you provide may be used for secondary Project Address(if di rent than mgai ng address) <br /> purposes in accordance with the Privacy Law,s. 15.04 1 (m),Stats. _ r 51 <br /> I. Application Information-Please Print All Information _/_ 14$0 <br /> ProD=Owners Name Parcel# <br /> Property Owner' M7aiing Address Property Location <br /> �c 5 / Ge_/ Govt.Lot <br /> Ci ,State ` Zip Code Phone Number 'A, /4, Section <br /> (circle one) <br /> tel <br /> L C� d vl `, ; R E o(5 <br /> II.Type of Building(check all that apply) Lot# <br /> 0-r&2 Family Dwelling-Number of Bedrooms_ Subdivision Name <br /> ❑Public/Commercial-Describe Use Block# <br /> ❑ City of <br /> ❑State Owned-Describe Use El Village of <br /> CSM Number <br /> D-Town of c_ <br /> X. <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(explain) <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/Component/Device: (Check all that apply) <br /> Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Dispersal Area Required(sf) Dispersal Area Proposed(sf) System a ation <br /> '�� Rate(gpdsf) 17 o <br /> 7 ^� <br /> C s� <br /> VI.Tank Info Capacity in <br /> Gallons <br /> Total #of <br /> Manufacturer '� U o <br /> Gallons Units 2 0 y 2 0 <br /> New Tanks Existing Tanks y U <br /> Septic or Holding TankMao <br /> Lw 4' Z-� ❑ ❑ ❑ ❑ fl <br /> Dosing Chamber ❑ ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement- I,the undersigned,assurpf respo sibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber' igna MP/MPRS Number Business Phone Number <br /> Co Jackson 824339 715-566-2786 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 9306 Black Brook Road,Webster,WI 54893 <br /> VIII.County/De artment Use Only _ <br /> Approved ❑ Disapproved Permit Fee Date(Issued Iss ent Sig tul <br /> El Owner Given Reason for Denial $ 00 7/.�q ,wq C� <br /> IX.Conditions of Approval/Reasons for Disapproval �� �a �p <br /> be 5-M ONWn D � O V E <br /> MUV- loc. SoFi <br /> n 1111 7 4 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 t[hetY i size <br /> Burnett County <br /> SBD-6398(R03/14) Land Services Department <br />