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'+*%'g" *i' County <br /> rs Industry Services Division RtA vn e <br /> 4 °:. eta <br /> _ jF p' 1400 E Washington Ave Sanitary Permit Number(to be tilled in by Co.) <br /> P.O. Box 7162 ,.hm <br /> ' , .�--:•rkP Madison,WI 53707-7162 <br /> Sanitary Permit Application State Transaction NIT <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 Project Address(if different than mailing address) <br /> the Department of Safety and Professional Servies. Personal information you provide may be used for secondary 377 L/ <br /> purposes in accordance with the Privacy Law,s.15.04(I)(m),Slats. <br /> I. Application Information-Please Print All Information R-evi t Tr e-f <br /> Property Owner's Name Parcel# <br /> Property Owner's Mailing Address Property Location <br /> pe 3e x 3 <br /> Govt.Lot <br /> City,State Zip Code Phone Number y, y., Section 13 <br /> V_760— CIO 70 (circle one <br /> 11.Type of Building(check all that apply) II Lot# <br /> T E/O N; R /S E ot� <br /> I or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use ❑ City of <br /> ❑State Owned-Describe Use <br /> CSM Number ❑ Village of <br /> IN Townof JoLGksaf', <br /> 111.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> X New System ❑ Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. El Permit Renewal El Permit Revision ❑ Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> TBefore Expiration Owner <br /> IV.Type of POWTS S stem/Corn onent/Device; Check all that apply) <br /> Kdri 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.Dis ers'aI/Treatment Area Information: <br /> Design FIow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(so Dispersal Area Proposed(st) System Elevation <br /> .306 e 7 �dY y3�t Sys <br /> V1.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o <br /> New Tanks Existing Tanks c <br /> Septic or Holding Tank 7J 73-0 1-eJ.<J/ /c <br /> Dosing Chamber.. t <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 MP/M IRS Number Business Phone Number <br /> R c% No k,h iq IXJ I z/0-7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> VIII.Court /De artment Use Only <br /> C46pproved ❑ Disapproved Permit�Fjee Date Is ed Is Agent Si ature <br /> ElOwner Given Reason for Denial $ t�• 00 I o � � <br /> IX.Conditions of Approval/Reasons for Disapproval F <br /> E 0 1`I E <br /> APPROVED <br /> OCT 0 2 2019 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 s 1 inche in size <br /> Burnett County <br /> Land Services Department <br /> SBD-6393(110313) 6q �q� �t, - <br />