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County <br /> Industry Services Division �wYy1 <br /> r 1400 E Washington Ave Sanitary Permit Number(to be tilled in by Co.) <br /> P.O. Box 7162 <br /> Madison, WI 53707-7162 <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 &2•013 4- <br /> is required prior to obtaining a sanitary pennit. 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 <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Slats. <br /> I. Application Information-Please Print All Information e Rv o q e 154 /U <br /> Property Owner's Name Parcel# <br /> Mo.,. i< wti ; fe dS-L, 4.70OF CQ <br /> Property Owner's Mailing Address /� Property Location <br /> 6 S H t �• l k e h 1 K� r V Govt.Lot <br /> City,State Zip Code Phone Number / y,, Section <br /> M e h r1 0,6011J tkN A/ __J.Sr 41 7 O (circle one) <br /> Il.Type of uilding(check all that apply) Lot# T N; R E or�V <br /> 12 1 or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use ❑ City of <br /> ❑State Owned-Describe Use ry, <br /> CSM Number ❑ Village of <br /> IrO Town of ,SG c?V <br /> Ill.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. ❑ Pennit Renewal ❑ Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Pen-nit Number and Date Issued <br /> Before Expiration Owner <br /> IV.I e of POWTS System/Component/Device: (Check 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 /> 5d Ftoldin.Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dis ersal/Treatment Area Information: <br /> DesignFlow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(so Dispersal Area Proposed(st) System Elevation <br /> VI.'Tank info Capacity in Total #of Manufacturer <br /> y <br /> Gallons Gallons Units o <br /> New Tanks Existing Tanks v o _m <br /> G U ci7 H cn Gz.C7 0. <br /> Septic or Holding Tank O 00 s�G sL t. <br /> Dosing Chamber.. <br /> j <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/MPRS Number Business Phone Number <br /> /C t L/-/ 6 A0 k/h f �C�.�-wC /� s �!/H S <br /> Plumber's Address(Street,City,State,Zip Code) <br /> VIII.County/Department Use Onl <br /> Perna Fe bo Date[sued u' a gent Sigma re <br /> Okpproved ❑ Disapproved $ O/� t <br /> ❑ Owner Given Reason for Denial ✓ /O 30 aAAA-1- <br /> IY.Conditions of Approval/Reasons for Disapproval 4C <br /> 6 � <br /> � V <br /> IE <br /> n, OCT 3 0 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 inc1lQy in tim <br /> t <br /> Burnett County <br /> Land Services Department <br /> SBD-6398(R0313) <br />