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;, !fi , Industry Services Division County n <br /> 1400 E Washington Ave Of-NCR- <br /> liff. <br /> Pi ' I P.O.Box 7162 <br /> �=1 �, a Sanitary Permit Number(to be filled in by Co.) <br /> $ Madison,WI 53707-7162 ' -020 _4t- <br /> Sanitary Permit Application StateTranslctionNumber <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit W.074* <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 ��441-114 V_purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. �55 <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name /� Parcel# Id la Di <br /> 4t'�ec- je IAJ o7o/42-3?*Otiii 7 04-000-0/10,o <br /> Property Owner's Mailing Address Property Location <br /> 8 `�6Z O.( //n Govt.Lot <br /> City,State Zip Code Phone Number / 2 / <br /> Section <br /> W edoe .�„r; Sys q3 /,. trcle one) <br /> j / <br /> T 7 N; R I EorC <br /> II.Type of Building(check all that apply) Lot# <br /> [?! l or 2 Family Dwelling-Number of Bedrooms 3 /D Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> 0 City of <br /> ❑State Owned-Describe Use CSM Number 0 Village of <br /> V' /92/6VI Town of LI`Nco fir/ <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. New 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 Change of PlumberList Previous Permit Number and Date Issued <br /> 0 Permit Transfer to New <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 Lei 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 Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 1/5V / U If 56 1/66 97? <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units vo u <br /> New Tanks Existing Tanks cy 1 . ca <br /> c. U -en y rn w 0 cs, <br /> Septic or Holding Tank /060 debWtti <br /> Dosing Chamber oo <br /> VII.Responsibility Statement-I,the undersigned,assume sponsibility for installation of the POWTS shown on the attached plans. <br /> PL <br /> Name(Print) / Plumber's i3 aturc MP/MPRS Number Business Phone Number <br /> Z(,-//QAJ/ /G�� "7 952/ 76--5W-ozo.-Z <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 6 S8/ / 2Vw A/ l le ,/ kle65er LA' 5169 3 <br /> VIII.County/Department Use Only <br /> pproved 0 Disapproved Permit Fee Dat Issue ant Signator <br /> 0 Owner Given Reason for Denial $ � ��0 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> ar Alt Oak coKd►'ttovM,S wutSt be w4,4, [ (�' [ Q d � � <br /> 4 OA %MAO toe 50{4 Alt" ablIKr�a�Q. COIM pettet.i,f; D <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 la x 11 int ws i size APR 1 7 2020 <br /> Burnett County <br /> SBD-6398(R.08/14) Land Services Department <br /> e Mt' 11425.46 <br />