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® "°L' Industry Services Division County <br /> �ul1400 E Washington Ave <br /> a1 `:a p P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> S Madison,WI 53707-7162 31N-a n-A <br /> Sanitary Permit Application State Transaction <br /> Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit Ghon <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 Services.Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. — <br /> I. Application Information—Please Print All Information <br /> Property Owner's Name Parcel# ii 22005 <br /> ©VP k1644AWV tgvIZ-t*4-11-q a_w./-ei+>r✓_o <br /> Property Owner's Mailing Address A' � Property Location <br /> OZ% Z 57 five/v' / �l art.Lot .i <br /> City,State Zip Code Phone Number NW �y Z 7 <br /> �1 ♦ C�/ { L' S /� Section <br /> a a'I vbtr, UV) 9 5)6 -7'/F-656-3?;', T a4" N; R (circlEe on W <br /> II.Type of Building(check all that apply) Lot# �C <br /> 1 I or 2 Family Dwelling—Number of Bedrooms 3 3 Subdivision Name <br /> Block# <br /> ❑Public/Commercial—Describe Use <br /> 0 City of <br /> ❑State Owned—Describe Use CSM Number 0 Village of <br /> I /zO gg Town of $tt/i 4 <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> 0 New System replacement System 0 Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> B. 0 Permit Renewal 0 Permit Revision 0 Change of PlumberList Previous Permit Number and Date Issued <br /> 0Permit Transfer to New <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> 5;Non-Pressurized In-Ground 0 Pressurized In-Ground 0 At-Grade 0 Mound>24 in.of suitable soil 0 Mound<24 in.of suitable soil <br /> ❑ Holding Tank 0 Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design F ow(g d) Design Soil Application Rate(gpdsf) Dispersal Area Required(s0 Dispersal Area Proposed(sf) System Elevation <br /> 75 . i If 6iS 930 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> la Gallons Gallons Units .13 ;r o <br /> New Tanks Existing Tanks v c •-•' . <br /> Y 2 y it- 6. <br /> ill 1% <br /> Z. U in v <br /> el' o <br /> Scptic or Holding Tank //w/10 //t/yy /�I A`, ' Y. <br /> Dosing Chamber ((/{/ (Kitr� j� 7��i Vv \r( <br /> VII.Responsibility Statement.-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plu cr's Name(Print) Plumber's 'g ture MP/MPRS Number Business Phone Number <br /> Atm T//QAti /��� 857952/ 7/1--sg-a2oz <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 613 el % 7AI lA ,/ kle6LA- 5 / 93 <br /> VIII.County/Department Use Only <br /> / Approved ❑Disapproved Permit Fee Dat Issue ssuin gent Signal e <br /> (/ 315 00 31 02(' <br /> 0 Owner Given Reason for Denial <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> . fa atiUsy S w <br /> fo be. rcAoved per oat f'lafc s <br /> tircwctK <br /> $'4,2)/ 90 <br /> atmAl yrw <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 in x Esin size <br /> MAR262020 J <br /> SBD-6398(R.08/14) Burnett County <br /> Land Services Department <br />