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.vEeaRT'rctr� Coun � J <br /> � � D <br /> Industry Services Division <br /> a � 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> P r P.O.Box 7162 <br /> Madison,WI 53707-7162 <br /> Sanitary Permit Application State Trrrmsaetim Number <br /> In accordance%tith SPS 38321(21 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 different than mailing address) <br /> u es in accordance a itch the Privacy Law,s.I5_04(lxm},Slats. <br /> I. Application Information-Please Print All Information / Cf <br /> Property Owner's Name panel i' O A — <br /> Property Ott Mailing Address Property Location <br /> 7 C 3 /-� l�. Go-t Lot City, tare Zip Code Phone Number LXZ 14,4-e Va, Section <br /> c!rele one) <br /> T 7Q�' RIEo tr <br /> II.Type of Bui ng(check all that apply) Lot Y <br /> I or 2 Family Duelling-Number of Bedrooms Subdivision Name <br /> ❑Public/Commercial-Describe Use Block- <br /> State Owned-Describe Use ❑City of <br /> CSM Number ❑Village of <br /> Tovriof <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 Renewal ❑ Permit Revision ❑Change of Q Permit Transfer to Nets List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IV.Type of POWTS Systern/Com onent/Device: (Check all that a pl r) <br /> Non-Pressurized In-Ground ❑Pressurized In-Ground _❑ At-Grade ❑tiloumd>34 in.of suitable soil ❑Mound<24 in.of suitable soli <br /> ❑ Holding Tani: ❑Other Dispersal Component(explain) Q Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: S -- <br /> Design Flow(apd) Design Soil Application App Dispersal Area Required(s#) Dispersal Area Proposed(s0 System Etevaturrr rr <br /> VI.Tank Info Capacity in <br /> Gallons <br /> Total A of P <br /> New Tardy Faistine Tanks Gallons Manufacturer <br /> Septic or Holding Tani: (�� f?0�- ` ❑ ❑ El <br /> C <br /> Dosing Charger ❑ ❑ ❑ ❑ C <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the PO`N TS shotsn on the attached plans. <br /> Plumber's Name(Print) Plu s Si a iviP,Vi <br /> Number Business Phone Number <br /> G��' �?- ,� �7 7�s--;76.Q ry <br /> Phunber's Address(Street City,State,Zip Code) <br /> VIII.Conntv/De artment Use Onh <br /> Approved ❑ Disapproved Perm��e., J�8�7asue l ssu ent Sim re <br /> Owier Given Reason for Denial 5 2 <br /> IX.Conditions of Approval/Reasons for Disapproval �] <br /> A PPw K08,0 <br /> Eg <br /> V I'D <br /> qn A I In n <br /> Attach to complete plain for r§e.%stem and sub=it to the Connh oarh on paper not tan tlna 8 rt2 <br /> Burnett County <br /> Land Services Department <br />