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"''-* Industry Services Division County <br /> - � 1400 E Washington Ave trove <br /> ; <br /> pi `® ;Sp P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> .`• S Madison,WI 53707-7162 • <br /> 5Ad-AO-$5 <br /> , ,,.. LST- ;�o-�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 o2+t71/2 <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 secondaryp /� <br /> I. es in accordance with the Privacy Law,si 1 All Information <br /> Stats. 209' �������/�� / tt32a <br /> I. Application Information-Please Print All Information / /� <br /> Property Owner's Name I Parcel# <br /> aYvt f�Ntd9e Al 07012.4441/5-'175i6"'XIT•eZ <br /> Property Owner's Mailing ON <br /> �/�1 lj /f�L/� Property Location <br /> �'/ �'w4f'GI %j I �/ Govt.Lot <br /> City,State Zip Code Phone Number lZ <br /> �/� �, ,�t f Q pry-/A� / 2// 9 14, /�, Section <br /> /%rN/�ri/vA1k1 /6 551K -eif G��� �/�� cle one <br /> T -/(/ N; R E o V <br /> II.Type of Building(check all that apply) Lot# <br /> l or 2 Family Dwelling-Number of Bedrooms /° Subdivision Name <br /> Block# kyIy/it444 le <br /> ❑Public/Commercial-Describe Use ❑ City of <br /> ❑State Owned-Describe Use CSM Number yy❑,, Village of <br /> lltl Town of 74 e k ,o*.J/ <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. �'y <br /> L14 New System 0 Replacement System 0 Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> B• CIPermit Renewal 0 Permit Revision ❑ Change of Plumber 0 Permit 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 /> VI Non-Pressurized In-Ground ❑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 a Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 72CC1 r 7 g27 *#6 7 / <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units az s'''4 o <br /> New Tanks Existing Tanks .`2C E r, a`, y y <br /> t:", U in h Cl) iZ C7 al 0. <br /> Septic or Holding Tank is,oO ,/jKam/ jt,r) � Au4•1oocsi r y <br /> Dosing Chamber <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> PN cr's Name(Print) i Plumb s ignature MP/MPRS Number Business Phone Number <br /> Ot* 0V/fat/ 0T)/A-7 86/95-4/ <br /> Plumber's Address(Street,City,State,Zip Code) <br /> G 8/ IvM a t e // kJe6S Lk 94E39 <br /> VIII.County/Department Use Only <br /> Ca.Approved 0 Disapproved Permit Fee Dat Iss ling ent Signa e <br /> S oo 6/,/a 2030 <br /> 0 Owner Given Reason for Denial <br /> IX.Conditions of Approval/Reasons for D• appr wal <br /> DVIt+•Kri't ww* in %Oft Klee ti <br /> t Aft Mkt Sdioa,tk$ oft fo be. stet. 22 E p 2 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 inike <br /> MAY 19 2920 i I <br /> SBD-6398(R.08/14) Burnett Count <br /> Land Services Department <br /> /'1/• 40<a 4.l-)loo <br />