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/-. :a''*;-. County <br /> f.,•',7(.... '`t--\ IndustryServices Division �u r h e- <br /> ft <br /> ti` 0 1400 E Washington Ave Sanitary Permit Number(to be tilled in by Co.) <br /> 4..„ S 1 P.O. Box 7162 ifiN_,,20 _.22,2 <br /> s:'-.1:-.•. 7x-, Madison,WI 53707-7162 <br /> --,-4-•;_,,,v,4,-, CSr•'20-Lori 42S37 9 <br /> - <br /> State Transaction Number <br /> Sanitary Permit Application <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 Servies. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. <br /> I. Application Information-Please Print All Information G-+..1 {— <br /> Property Owner's Name Parcel# 3o`..../S-O g-a Co <br /> Pit;Cil AC 1 - ? vvy G ill 'S O7-O�l�-A. ce,o -G'//C9oo <br /> Property Owner's Mailing Address Property Location <br /> 141-5-170 'o RdZg�BN <br /> Govt.Lot <br /> City,State Zip Code Phone Number , 8 <br /> /, <br /> /<, Section <br /> 6 vAr c.SOt.i'' WI- S`y 84f° (circle one <br /> j„, <br /> 3 S N; R /er E AV <br /> II.Type of Buildin (check all that apply) Lot# <br /> ❑ I or 2 Family Dwelling-Number of Bedrooms 3 Subdivision Name , <br /> Block# <br /> ❑Public/Commercial-Describe Use ❑ City of <br /> ❑State Owned-Describe Use p <br /> CSM Number ❑ Village of <br /> ® Town of t"0C gwev <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• ❑ 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 /> a Non Pressurized In-Ground ❑ Pressurized In-Ground ❑ At,Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑ Holding Tank 0 Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispers tl/Treatment Area Information: _ <br /> Design Flo*(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> 4/-re , S Soo Sao <br /> g6. 3 <br /> VI.Tank Info Capacity in Total 4 of Manufacturer a, <br /> Gallons Gallons Units o o <br /> N <br /> New Tanks Existing Tanks o v 2 Y 0 Ti 0 m <br /> c.U ti rn ii C7 m <br /> Septic or Holding Tank fO00 /bOa <br /> ) /Dosing Chamber.. — (,00 6,00 ' �i�s�r i •4', <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 NIP/MPRS Number Business Phone Number <br /> /2/GISf/o /Z. dt,t_sfs,/ 7/.1%W-- yis7 <br /> � ,Hf <br /> Plumber's Address Street,City,State,Zip Code) <br /> 77 G 0 . .- ..Z.5-- Gt/ 6s-/`r.- t 'z 3-?7`Sg <br /> VIII.County/Department Use Only <br /> Approved ❑ Disapproved Pennit Fee Date Issued issuing Agent Signature <br /> ❑ Owner Given Reason for Denial 37 i• i(� ..z_±,__ _ ._________.--7 <br /> Z D <br /> --- <br /> la.Conditions of Approval/Reasons for Disapproval e.1 --41 <br /> ►l �(a/�I 275 <br /> D , <br /> �j JI <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 a ll•nc in si�i.,,.+ 0 7 2020 <br /> Burnett County <br /> SBD-6398(80313) Land Services Department <br />