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03,Rra,t;1,1. Industry Services Division County <br /> o� . 1400 E Washington Ave +�14A-ot.i-i <br /> 3'cep$ P.O.Box 7162 <br /> rt Permit Number(to be filled in by Co.) <br /> `` p$ I Madison,WI 53707-7162 20 <br /> Arov.i-4 <br /> b-83 tri' <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 <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 /0 <br /> Z i V . —4.4.0? ,,,rdD <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. <br /> I. Application Information—Please Print All Information <br /> Property Owner's Name Parcel#67—Rat,-1- f .17 <br /> K1/4c.`+ ��'oNfo-ii?t. 01/-400- 01 L.0000 �y t1 <br /> Property Owner's Mailing Address Property Location �C d'r"L� <br /> hi? Z z 42 0 at,f Govt.Lot <br /> City,State Zip Code Phone Number8 <br /> ` S£ '4,�C 'A, Section / <br /> 1 .(.t(_lf , S tl SJ 3 '/'t Y7L-g/S y (circle one <br /> II.Type of Building(check all that apply) Lot# T �'j N; R E of <br /> .1...K or 2 Family Dwelling—Number of Bedrooms d' Subdivision Name <br /> Block# <br /> ❑Public/Commercial—Describe Use <br /> ❑ City of <br /> CIState Owned—Describe Use CSM Number 0 Village of <br /> El Town of DaJvit1S <br /> III.Type of Permit: (Check ly one box on line A. Complete line B if applicable) • <br /> A. ❑New System Replacement System ❑Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> ) <br /> B. CIPermit 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 /> /Holding <br /> on-Pressurized In-Ground CIPressurized In-Ground CIAt-Grade CIMound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> 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 /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units 8 o v v <br /> New Tanks Existing Tanks w c y t). ',T) <br /> a'' U 65 .W U ak <br /> Septic rHolding y //� / S/��w y <br /> Dosing Chamber /_ /� /` <br /> .Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shpuLan the attached plans. <br /> mber's Name(Print) Plumber's Signature <br /> 4 MP P$8'Number Business Phone Number <br /> a �'� aw kit. w,., 2.2-2.F77.- 1/S--'/9/-.1388 <br /> P ber'tAddIess(Street,City,State,Zip Code) <br /> e.o . a. k u ckl lam', S4 913 <br /> VIII.County/Department Use Only <br /> 14 <br /> pproved 0 Disapproved Permit Fee Date Issued Issuiing Agent <br /> ignature <br /> El Owner Given Reason for Denial $ 3?.S Ii D yy'2a K!. /'l <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Utt Rely 5375. <br /> ECEOVIE ) <br /> Attach to complete grins for the system and submit to the County only on paper not less than 8 1/2 x11 i,r es ize <br /> SEP <br /> 2 8 2O <br /> 20 <br /> Burnett County <br /> SBD-6398(R.08/14) Land Services Department <br />