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/ <br /> v "RT"r * Industry Services Division County <br /> 1400 E Washington Ave U r h <br /> S F P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> S Madison,WI 53707-71b2 501-L9 _ <br /> .,✓�, 4- to L407 <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 <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. De/5/4, &G I h a r R b <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> re-rrti c- ÷ id bAcki DA- 0 , ?ec ke.r TMK ID Igcq <br /> Property Owner's Mailing Address Property Location <br /> 70/ q 4 S Govt.Lot <br /> City,,�State Zip Code Phone Number vi, Y,, Section 0(p <br /> f ra i r t F14-e441 3-1../.7 (1"Z 7 I S -a9(e-a�1 qctrcle one <br /> T tN; R E ort <br /> � .) <br /> II.Type of Building(check all that apply) Lot# q <br /> X1 or 2 Family Dwelling-Number of Bedrooms 1 3 TA Subdivision Name <br /> Block# /' 1 NA'L �- �3ai� 1-1'4-Show 5 <br /> ❑Public/Commercial-Describe Use /,-NSCO4l\ "" <br /> 5 IRDS 0 City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> ' .TKv� <br /> own of San 7 r <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' 0 New System �ePlacement System ❑Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> ) <br /> B. 0 Permit Renewal 0 Permit Revision 0 Change of Plumber ❑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 /> ❑Non-Pressurized In-Ground 0 Pressurized In-Ground 0 At-Grade 0 Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.DispersaUTreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units 0 o 'La o <br /> Ncw Tanks Existing Tanks a Ta " re)a p m <br /> 0 <br /> aU in 4 in 26 a <br /> Septic or Holding Tank x060 <br /> "1 / tt t` Ciz- 4. <br /> Dosing Chamber <br /> VII.Responsibility Statement-1,the undersign sume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) DA- AJ P1 's Signature MP/MPRS Number Business Phone Number <br /> 117/OO 2 ) 1 am...,g�: . 71190 a 7h--4/18—14,08/ <br /> Plumber's Address(Street,City,State,Zip Code) I <br /> •13ga 13H-5t Fe-2rzo,-J wt 5-t( > z- <br /> VIII.County/Department Use Only <br /> Approved ❑Disapproved <br /> Permit Fee Date Issued Iss ' g ' 1-,,a t i=a•a.e <br /> }� <br /> 0 Owner Given Reason for Denial <br /> $ 375 3-/ s-�9 ��{,,. i <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 112 i3ECEOVE <br /> feS imiAR 1 5 2019 <br /> Burnett County <br /> SBD-6398(R.08/14) Land Services Department <br />