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?:.,' \ Industry Services Division County /J <br /> 1400 E Washington Ave VOV <br /> l=I �.\$p P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> $ .. Madison,WI 53707-7162 <br /> , �'` C$1 —20 29 <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 (;002 <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(l)(m),Stats. /�„A /f <br /> I. Application Information-Please Print All Information //VCi�LW�//61/ <br /> Property Owner's Name Parcel# <br /> W OWA ToN,leiri 0r-10/12 yv-fir-2 6z -©M An <br /> Property Owner's Mailing Address Property Location ,d 3�f Z,I�\ <br /> 12,0 �cr/ 4/- Govt.'NV <br /> q/uT� <br /> City,S ate Zip Code Phone Number Nut/ y, VW%,, Section <br /> IAq1�1t)1/J W le <br /> 51002_ ,,4.e.ucle one <br /> T 7V N; R / E or <br /> II.Type of Building(check all that apply) Lot# <br /> yr I or 2 Family Dwelling-Number of Bedrooms f Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> 0 City of <br /> ❑State Owned-Describe Use <br /> CSM Number 0 Village of <br /> (►Town of Pi GN <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. lyNew System y 0 Replacement System 0 Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> B. 0 Permit Renewal 0 Permit Revision 0 Chane of PlumberList Previous Permit Number and Date Issued <br /> g 0 Permit Transfer to New <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> FrNon-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 pd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 11 . 7 /yg , 648 r14/8 9fl, <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o "0 <br /> New Tanks Existing Tanks w; It .ay b ca <br /> y <br /> ? 0 g 2 <br /> aU in H m i. (.7 a <br /> Septic or Holding Tank /tr) /2 -1--- 3 fr- IkJ j/ <br /> Dosing Chamber <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plu cr's Name(Print) / Plumber's ' n rc MP/MPRS Number Business Phone Number <br /> (i* 1/kat/ � �/GAG 7 "57952/ 7/5 la-azoZ <br /> Plumber's Address(Street,City,State,Zip Code) / <br /> beet ,4 w CA 41 (ve6 /- LA. 5'189 3 <br /> VIII.County/Department Use a <br /> Only <br /> pproved ❑ Disapproved Permit Fee Dae sue Fgent Siate /0400/0404....t. <br /> ❑Owner Given Reason for Denial $ 315. ' ifi ;$02.60 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> * Ail wtust 64 50 fwVtt, D ttAgfict• <br /> 3 tPraMP444 wcLaf 106 £wtl. 0 V E <br /> A $&LS+ 1.466 at /& f 32 'KR Vs 4'Gbtd cwt 4J.+ t` <br /> Attach to complete plans for the system and submit to the County only on paper not less tan /2 x Ws in Immo <br /> Burnett County <br /> SBD-6398(R.08/14) Land Services Department <br /> C- $4/x5 <br />