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+"'r'� Industry Services Division Cly <br /> 1400E Washington Ave 13 ti b <br /> i'� �r ' p, P.O.Box 7162 Sanitary Permit Number(to be filled in by Ca) <br /> 6‹_ /7' Madison,WI 53707-7162i\l �+n) '3''° 35 <br /> 3'o'35 C61- O-35 <br /> Stat <br /> Sanitary Permit Application eTnmaacti°° J, <br /> In accordance with SPS 38321(2),Wis.Adm.Code,submission of this form to the appropriate govunm l unit / �� <br /> is required prior to obtaining a sanitary penin Note:Application forms for state-owned POWTS are submitted to (if different thea 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 l5.04(1 Xm.k Stats. Wig <br /> g <br /> I. Application Information-Please Print AR Information V ( 1 � [ /(f <br /> Property Owner'S Name \ Pascal t< 07-032--1-yi_/4,--2v-5- <br /> FC!'VALD E. k � "E0 E. bi L :A-NE ----- z54::, -- 0/3000 <br /> Property Owner's Mailing Address Property Location ti 2•24000 <br /> Z'-I( t c c C- ROAD Govt.Lot — <br /> City,State Zip Code Phone Nnmoba- y., - y., Section 24 <br /> NBu jzy 5ii 536 3CR- ZLI one <br /> II.Type of Bt (cheek(chean that apply) Lot f T 4) N; R /�P Eat <br /> AI or 2 Family Dwelling-Number of Bedrooms -3 3 Subdivision Name <br /> Block# CRI-FF -ACRES <br /> 0 PablidCommecial-lenatbe UseNit 0 City of <br /> 0 State Owned-Dtmxnbe Use CSM Number 0 v, a of <br /> ivA fr A]Tawe of s J( <br /> M.Type of Permit (Cheek only oro box ea line A. Complete lite B if a ppGeable) <br /> A. A New Sym 0 Replacement System 0 Treatment/Holding Tarr Replant Only 0 Other Modification to Existing System(explain) <br /> lt. 0 Permit Renewal 0 Permit Revision 0 Change of Phamber 0 Permit Transfer to New List Previous Permit Number aid Date hated <br /> Before Expiration Owner <br /> IV Type of PORTS SystetalComposeatiDeviem (Check at that apply) <br /> 'Non-P ;rod to-Grams 0 Pressurized In-Ground 0 A:-Grade 0 Mani>24 in.of suitable sod 0 Monad<24;a&s, soil <br /> 0 Holding Tank 0 Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> V.DispersanTrestaseat Area Information: <br /> — <br /> Design Fknv(Bpd) Design Sod Application Rat(8pdst) Dispersal Area Required(st) Dispersal Area Proposed(st) Systan'Elevati/on <br /> 450 Q. 7 Ze is w . W,,PO <br /> VI.Tank Info Capacity in Total I of - Manufacturer <br /> Gallons Gallons Units m i € a <br /> New Tasks Talks is gi <br /> U �- !p <br /> U m co tics <br /> Sepi"oriteldiartark j,oei� ►,ono 1 Wtr'r >C <br /> VII.RespoeminTsty Sta tan nt-I,the undersigned,assume responsibility be instaBatien.f the PORTS shown as the apaehed pans. <br /> Plumber's Name(Print) Plumber's <br /> MBOAIPS&Nimsber Bre Phone Number <br /> eo v-3...1;teKs0A1 S 24 33? 7, -&,i.--?dF `/ <br /> Plumber's Address(Street,City,State Zip Code) <br /> 93 o,b 411.4eK BROOK Rao, s, "a s1 rq.3 <br /> VIII.Comity/Department Use Only <br /> clitApproved 0 Disapproved Ptstait Fee ote <br /> 0 OwneGiven Reason for Denial S 3 O° 113 A0207:00x,9-4-4--k------' <br /> IX.Conditions of seA Dsappr oval <br /> S 4a5.00 <br /> e4.-* ( s 345 <br /> Atte&to eamplele plow tr the spies sor.nbatt a.tile Camay'sly.. .aslessli et,.. . - 0 M. •1 rte. <br /> Ti i 0 - <br /> Li)a <br /> SBD-6398(It 08/14) Ipi Mh( 13 2020 I ,1 <br /> _ _J <br /> Burnett County <br /> Land Services Department <br />