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County / <br /> Industry Services Division LJ <br /> r :. <br /> i 1 1400 E Washington Ave Sanitary Permit Number(to be tilled in by Co.) <br /> P.O. Box 7162 <br /> Madison,WI 53707-7162 — ����g3 <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 �;vsx?_ <br /> is required prior to obtaining a sanitary permit. Note:Application forms for state-owned PO4VTS are submitted to Project Address(if different than mailing address) <br /> the Department of Safety and Professional Servies. Personal infonnation you provide may be used for secondary d 6 <br /> purposes in accordance with the Privacy Law,s.15.04(I)(m),Slats. <br /> I. Application Information-Please Print All Information 6 r ese Pi' 4o:,c-- <br /> Property Owner's Name Pei# <br /> v o <br /> Property Owner's Mailing Address Property Location <br /> 1766 Le—'se-h Govt.Lot <br /> City,State Zip Code Phone Number ,' , <br /> 1 [ /<, Section <br /> J � <br /> LL V-1 rc 1/11 T L/5V L circle one <br /> II.Type of Building(check all that apply) / Lot# T UO N; R / E or( <br /> I or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> d <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number 0 Village of <br /> Town of SCr7I� <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. :Q New System ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑ Permit Renew a] ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS S stem/Com onent/Device: Check all that apply) <br /> 11 iron Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> lfoldingTank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dis erW/Treatment Area Information: <br /> Design FlovY(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units 0 9 <br /> New Tanks Existing Tanks o u a m <br /> i c,U in y in ii U a <br /> Septic or Holding Tank 450 .75-0 ''j 60 I w I E=sC,^ <br /> Dosing Chamber.. 1 <br /> VII.Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> �z l �►� �-�� ��,�, s ��,,.�...� �t � �ds'�-s`r ��s ,��� -yes-7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> VIII.Coun /De artment Use Only <br /> roved ❑ Disapproved Permit Fee Mf <br /> m ent Signa e <br /> 216 PP $ 3 oo Oil 7- <br /> ❑ Owner Given Rea§on for Denial <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> APPROVED <br /> SEP 13 20+9 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 1 inche in size <br /> Burnett County <br /> Land Services Department <br /> SBD-6398(110313) <br />