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''`-`-'<' Industry Services Division County n <br /> 1400 E Washington Ave Ut`Ne <br /> 1.! :_ Sp P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> $ Madison,WI 53707-7162 <br /> >.., , 5anJ—ao— 3a <br /> Sanitary Permit Application State Transaction <br /> QNugmber <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit bN r L7 • <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 /> purposesp ���3 d <br /> in accordance with the Privacy Law.s. 15.04(1)(m),Stats. <br /> I. Application Information—Please Print All Information NAgen 1k l/'//lr <br /> Property Owner's Name Parcel# <br /> 712 ik6 /%'/4 4,`et, ,�l 7-�6 2-3g-/7.2/-S =oa6-OZ/oaa <br /> Property Owner's Mailing Address /� Property Locationtiti t� • •6 <br /> '19/1 PeA l / Via Govt.Lot (7 <br /> City,State Zip Code v Phone Number � Zl <br /> /�, /,, Section <br /> incl N /&/ 56-122 • trcle one <br /> II.Type of ilding(check all that apply) Lot# T >(J N; R l E o <br /> FrI or 2 Family Dwelling—Number of Bedrooms 3 Subdivision Name <br /> Block# <br /> ❑Public/Commercial—Describe Use <br /> ❑City of <br /> ❑State Owned—Describe Use CSM Number ❑, <br /> Llt/Village of <br /> Town of 4 <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> ❑New System (Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. 0 Permit Renewal 0 Permit Revision 0 Change of Plumber List Previous Permit Number and Date Issued <br /> ❑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 ❑Pressurized In-Ground ❑ At-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> SI Holding Tank 0 Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design low(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> /6?, .--- <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units Y. <br /> o v P. <br /> New Tanks Existing Tanks u c v : d .°21 ,`,1 2 <br /> o N <br /> �j� �yQ(�� ci�./U in CA ii. C7 n, <br /> Septic or Holding Tank y �fwwll O /""sG A .4?- / " cs ( / <br /> Dosing Chamber PWIJ .Y t .�/ -� �/ W <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plu cr's Name(Print) / Plumber's aturc MP/MPRS Number Business Phone Number <br /> 0(* Vkati <br /> 86/954/ <br /> Plumber's Address/(Street,reCity.State,Zip Code), <br /> 6 8! Aw,n! L 1' , / tif e65 L✓.. 51169 3 <br /> VIII.County/Department Use Only <br /> iproved ❑ Disapproved Permit Fee Date sued .suing Ag t Sigaatur <br /> OS 6p 30 zo <br /> ❑ Owner Given Reason for Denial . <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> 1 Opt r4140 PAIre/aealt•e per 93'333, ck - 1 <br /> 0.Xeig iii MARS moo 6e "imuidiscleel per SE'S. 383 -.\ <br /> ilECEOVEAttach to complete plans for the system and submit to the County only on paper not less than 8 1/2 a 11 inche, • <br /> JUN 2 9 2020 J <br /> SBD-6398(R.08/14) Burnett County <br /> Land Services Department <br />