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'`"""`�� IndustryServices Division County <br /> .'r_._�'� <br /> f \'r` 1400 E Washington Ave vrnvr f' <br /> P.O.Box 7162 <br /> I=1 �. SS Sanitary Permit Number(to be filled in by Co.) <br /> Madison,WI 53707-7162 5 Yi'IJ —n, -5v <br /> ,,,,, LV <br /> -h 51-- it-11.5 <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 6;341 <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 493'35 /Q J/ 1,ve. <br /> Property Owner's Name Parcel# <br /> Property Owner's Mailing Address <br /> / Property Location <br /> 5-6g E 4 1 Govt.Lot <br /> City,State Zip Code Phone Number y, <br /> /, Section '9 <br /> / /V �y I R� s[i/ 7 01-1/7-1/96 <br /> T 116 N, R ' ircle ore) <br /> II.Type of Building(check all that apply) Lot# <br /> ❑ I or 2 Family Dwelling–Number of Bedrooms 3 Subdivision Name <br /> Block# <br /> ❑Public/Commercial–Describe Use <br /> 0 City of <br /> CSM Number 0 Village of <br /> ❑State Owned–Describe Use r <br /> IA Town of J'L1- <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> 0 New System Ireplacement 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 /> gNon-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 Flow gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(st) Dispersal Area Proposed(sf) System Elevation <br /> q .? ‘kQ& Gift) el .* gP, <br /> VI.Tank Info Capacity in Total 4 of Manufacturer <br /> Gallons Gallons Units JP ' o <br /> New Tanks Existing Tanks v o B i y eh <br /> eh <br /> C.: C..) cn y o :i. C7 0.. <br /> Septic or Holding Tank !//yt5 j�. e twee y <br /> Dosing Chamber 5q0A �V (1/V he " /� r X <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for installation of thelPPOWTS shown on the attached plans. <br /> Plu cr's Name(Print) / Plumber' nature MP/MPRS Number Business Phone Number <br /> /fAdv <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 6S8f %vyr w c/e ,/ kle6�/ G.A- 51/693 <br /> VIII.County/Department Use Only <br /> CKeeApproved 0 Disapproved Permit Fee Date I ued mg geture /04.4x <br /> 0 Owner Given Reason for Denial $ K S y�o�o <br /> IX.Conditions of Approval/Reasons for Disapproval / <br /> at ITT of Go'Jtr eves' dtaivr<rrI'Gld is Irk tcibesd. r,� <br /> • V.A 4t lot, loft cV 6N JtM. ' 51 f . Q4 ---F\') <br /> + a l� ' <br /> �tw�a�tl� s i� <br /> MAY ' ° <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 12 a fl inches in size i <br /> Burnett County <br /> Lahr' .:;.es Departmer. <br /> SBD-6398(R.08/14) 4.315°Dit Y9 <br /> I t o.,-.:LAA- <br /> s4,p'di L <br />