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�:',g;f"ter�r',. County <br /> --- <br /> /4;:r-;.; •' r� Industry Services Division /3u.r n-e-At <br /> r '� 0 �" 1400 E Washington Ave <br /> � ,� ,� �� 9 Sanitary Permit Number(to be tilled in by Co.) <br /> , o P.O. Box 7162 -lab <br /> /y� <br /> i-':i S '`/ Ao�1X20—!av <br /> h� Zi Madison, WI 53707-7162 <br /> .xj <br /> StateTransa/ctionNumber <br /> Sanitary Permit Application <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit v�83 <br /> isrequired 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 <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. " 5121.40%.t. " <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# ,,`..0- _i 01 -000 <br /> a7-O.LO-d-`�o' <br /> Cry is .S�t,t6, -043034- .=' -6ov <br /> Property Owner's la�iling Address �/ Property Location <br /> /' (1�-SG� JC//ow /21ve,' 17p ' Govt.Lot <br /> City,State Zip Code Phone Number %, /, Section 7 <br /> /J 4.111 ;k PI tv .57/44).30 D (circle one <br /> IL Type of Building(check all that apply) )) Lot# T G/ N; R /(o E or� <br /> El I or 2 Family Dwelling-Number of Bedrooms Ot /0 Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use ❑ City of <br /> CSM Number El Village of <br /> ❑State Owned-Describe Use <br /> ® Town of O ./-fai-' <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 g Treatment/Holding Tank Replacement Only ❑ Other N[oditication to Existing System(explain) <br /> B• ❑ Permit Renewal ❑Permit Revision ❑ 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 /> N'oness <br /> Prurized 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 Pretreahnent Device(explain) <br /> V.Dispersal/Treatment Area Information: _ <br /> Design Flo*(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> i B o . 7 Set t,+( S�l�tvur, 7t. 9 e,e/sem- <br /> VI.Tank Info Capacity in Total #of (j Manufacturer y <br /> Gallons Gallons Units o 70 o <br /> New Tanks Existing Tanks <br /> C.w Ug U a� y N <br /> B ' .c CI <br /> v� h cL C7 a <br /> Septic or Holding Tank /&..C.-o /9S0 / Z"r,F,'/710.,.....1- ,i X <br /> Dosing Chamber.. i .a <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POINTS shown on the attached plans. <br /> Plumber's Name(Print)inPlumber's Signature MP/MPRS Number Business Phone Number <br /> 2i C-iC- /1 00>/ci n S /2- Go -e, J7/4/V4etASes-/ 7iS�-' 9 457 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> j 7760 /-/�.y 3s' 14ie65Y...., /r 6-47,89 3 <br /> VIII.County/Department Use Only <br /> proved ❑ Disapproved Permit77Fee Date sued suing n_t_Signature' / <br /> 0 Owner Given Reason for Denial $ PS. " 8 24 24 / <br /> IX.Conditions of Approval/Reasons for Disapproval ,� <br /> Ja Niusf oul� be a Z bccrbcood..� ► E '�, [� II W <br /> is s+ew. to be. (ep(a�tteSt if cevmet rougi' s Per , <br /> I Sfak S1 1uke autpfer /y5. " <br /> 1 AUG 2 1 2020 <br /> Attach to completeplans he system and submit to the County only on paper not less than 8 in. in'. s in size <br /> Burnett County <br /> Land Services Department <br /> SBD-6393(80313) e k 4 I to - <br />