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y� 'x' 7h County <br /> �, f .r\ Industry Services Division at...v.n e <br /> e:1f; ^. • - �" 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> -5 ``'a . r'i P.O. Box 7162 SA -i/ <br /> \e Madison, WI 53707-7162 <br /> Sanitary Permit Application Staterran��sa''cNumber <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit 4^3{{tion 128 <br /> is required prior to obtaining a sanitary permit. Note:Application forms for state-owned POWTS are submitted to Project�� L, <br /> Address(ifdifferent 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),Stats. ..�7r1 . <br /> I. Application Information-Please Print All Information t <br /> Property Owner's Name Parcel# ,,! ,, _hi,ti p3_ coo <br /> t7 <br /> -d- <br /> jive Icis(ckifev oHeel/kW33 <br /> Property Owner's Mailing Address Property Location <br /> 3 1.16 o iew'v led Govt.Lot <br /> City,State Zip Code Phone Number / /,, Section 0 <br /> /aA hilur( Wx ,511 830 7/S•631 .76.43' (circle one) <br /> II.Type of Building(check all that apply) Lot# <br /> T 9/ N; P. /L E or6,y/ <br /> ® I or 2 Family Dwelling-Number of Bedrooms 2 Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use ❑ City of <br /> CSM Number ❑ Village of <br /> ❑State Owned-Describe Use <br /> 0 Town of .su-1Js <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' ❑ New System / <br /> � Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑ Permit Revision <br /> ❑ Chancre of Plumber ❑Pennit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> ®Nor Presstiized in-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑-HoldtngTank 0 Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> wso , 7 G y3 �v.8 9/. <br /> VI.Tank Info Capacity in Total #of Manufacturer v <br /> Gallons Gallons Units ;, o k <br /> V, <br /> Tanks New Tanks Existing Tan • o Y c_� <br /> C"..-u en H u.t i a. <br /> Septic or Holding Tank /6 O 6 /,Aa / -S'/G4 ry <br /> Dosing Chamber.. . I -).1 <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 /> /2/Lie- /-/m,/Ci i s /2 - L1 //, 0,(6As-8:5—/ 7/.s=576 A—Y1S'� <br /> Plumber's Address(Street,City,State,Zip Code) <br /> ci776o4y 3.3 w 6s7t>'r Li.--j— _5-yrs <br /> VIII.County/Department Use Only e <br /> Approved ❑ Disapproved $ennit Feed Dat Issu suing gent Signa / / <br /> 3461 <br /> ❑ Owner Given Reason for Denial <br /> IX.Conditions of Approval/Reasons for DisapprovalAPPROVED _ <br /> E © CDMGl� <br /> D <br /> MAY 1 3 2020 J <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 t/2 a I1 inctiyin <br /> Burnett County <br /> SBD-6393(80313) Land Services Department <br /> lb 1/ u- i r>I/I . 4 //ncy <br />