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seyr County <br /> � <br /> &x�{ Safety and Buildings Division Stagy^n: <br /> IKI 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> ' Madison,WI 53707-7162 <br /> �; �r SAN:AD-t�� <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 (02 g333 <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 Servies. Personal information you provide may be used for secondary � —3 <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. D <br /> I. Application Information—Please Print All Information ..-re 5-5.e <br /> 4 r <br /> Property Owner's Name Parcel# 0-7 0, p c/o /C <br /> Cry KAI 33 / s Sts a c�/7000 <br /> Property per's Mail g Address Property Location Z1 ly )44.9 <br /> _�„/p 1 <br /> 7 4 76 I) rf c-k /1 v Govt.Lot i''r7 7 <br /> City,State Zip Code Phone Number y. y,, Section 3 <br /> t/ lam <br /> W 4/0L(Ir )•y` 1/d 3 0 A — //f �2vZ (circle one) <br /> II.S� Type of Building(check all that apply) Lot# T yt'� N; R E o <br /> Al or 2 Family Dwelling—Number of Bedrooms / -7 Subdivision Name , <br /> Act <br /> # ,5 e$ L -/ Add <br /> ❑Public/Commercial—Describe Use <br /> ❑ City of <br /> -ice <br /> ❑State Owned—Describe Use CSM Number ❑ Village of /�/,3/0d <br /> 7 / <br /> T1`,own of 7 if N'C�{ <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. 74.-New System y ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑Permit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> (Ion-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil AQ <br /> pplication Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 7 <br /> _Fe, o e �� 3—O 5 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units 1, 5 o <br /> New Tanks Existing Tanks 0 2 . Q v a <br /> 41 U in , g fs, 8 P.. <br /> Septic or I44.14in etrtlt /O D /Q ao C r �—J Cr O 74— <br /> Dosing Chamber / / <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 /> Gr),4-ie-- kwf5A.,/m GtJc *6- X?/ 347/ -7--7:?G <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 4 a /y s; ,aJ `-rim- /S' 7.2.. <br /> VIII.County/Department Use Only <br /> ,pproved ❑Disapproved Permit Fee Deg ssui _Agent S%'/tore <br /> $ gel* /�rv. 20 <br /> ❑Owner Given Reason for Denial <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> ki J?r M4cAd t4W$1- frt ?sold Ast a welt E © E 5 / C <br /> )e <br /> EZ goo, ybutat ws.1- be Cuf OK. torH.tt/S. <br /> AUG 8 2020 1 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 inc in , r <br /> Burnett County —.1 <br /> Land Services Department,/ <br /> SBD-6398(R. 11/11) t9i /013 5725`'° <br />