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N <br /> ys "ae-k'.., County J <br /> ;;• :r\ Industry Services Division 1&K v'vl e <br /> ;Vi f: �t '� 1400 E Washington Ave Sanitary Permit Number(to be tilled in by Co.) <br /> js`' ,, ri P.O. Box 7162 SQA I_ `16g <br /> i t SW <br /> `�.---'fir Madison, WI 53707-7162 057 .a — go' <br /> . ,,, .1 <br /> Sanitary Permit Application State TransactionNumber <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit �2O5Z5 <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 d 7 d 14 <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. <br /> I. Application Information-Please Print All Information -Jaw 150r7 Vta <br /> Property Owner's Name Parcel# <br /> o7-oda-d.. I/0-l6-31-S-°S- <br /> ill <br /> sill 1C,ka4,I Wa 1 t Z In5 - oby - oi64Oco <br /> PropertyOwner'swner's Mailing Address Property Location It' �,j.�atSL u <br /> l' 1' J l - ,?I -'J' Govt.Lot 3�7 tigT <br /> City,State Zip Code Phone Number <br /> /,, Section ,?/ <br /> (NbitYv 1A)1 0 q3 (circle one <br /> IL Type of Building(check all that apply) Lot# T 4/0 N; R /b E ot�V <br /> ❑ l ort Family Dwelling-Number of Bedrooms 3 Subdivision Name <br /> • <br /> Block# <br /> ❑Public/Commercial-Describe Use ❑ City of <br /> CSM Number 0 Village of <br /> ❑State Owned-Describe Use <br /> ig Town of Ow/C/Rhyl' <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. New System ❑ Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(exp <br /> (explain) <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑Change of Plumber IDPermit 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 /> i2i N'on Pressurized In-Ground ❑ Pressurized In-Ground ❑ At,Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑ Bolding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V..Dispersiil/Treatment Area Information: _ <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> L/s-0 ' . 7 ti3 iso 9Y..r d. 9 y. o <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units a " o -o 0 <br /> U 1u +' <br /> New Tanks Existing Tanks ci o e,3 2 . e v <br /> a.U rn ti Cl) u..U a, <br /> Septic or Holding Tank /0 O e /e9d0 <br /> Dosing Chamber_ 00 G0'0 ; -) <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 Signa re MP/MPRS Number Business Phone Number <br /> R/e-k /4/0 kir s / i2/ vidsfr-5-7 74s-,96f '"fl <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 72/e X/t^. 35" Gv,e.45ter.- . t,✓-7' - 3'9_7 <br /> VIII.County/Department Use Only <br /> digiorApproved ❑ Disapproved Permit Fee Date[ ued o ent Signature // / <br /> DO <br /> ❑ Owner Given Reason for Denial $ sly �O 3030 Z:y0Ci��GT4& ,, r <br /> ter., . <br /> IX.Conditions of Approval/Reasons for Disapproval � � � � ^ „ � , <br /> 40 Al wcl/s WJA4+ be �50f4 Atm Aron etch! D V <br /> AUG 1 0 2020 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 l/_x 1 ch 1 n size <br /> Burnett County <br /> Land Services Department <br /> SBD-6393(R0313) <br />