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I% `' Industry Services Division County <br /> g. <br /> \� , <br /> \ 1400 E Washington Ave L c o e <br /> , ' P.O.Box 7162 <br /> tit. c, Madison,WI 53707-7162 Sanitary Permit umber(to filled in by Co.) <br /> C5--r'A7-18,, <br /> Sanitary Permit Application State Transaction Numbery <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit e... 2- p 3 G. 7 - <br /> is required prior to obtaining a sanitary permit.Note:Application forms for state-owned POWTS are submitted to Project Address(if diffeicnt pan mailing address <br /> the Department of Safety and Professional Services.Personal information you provide may be used for secondary / 3 4 s =A <br /> purposes in accordance with the Privacy Law,s. 15.04(IXm),Stats. (s /_� <br /> I. Application Information—Please Print All Information /eel . (] 5 <br /> Property Owner's Name <br /> Parcel# <br /> SSE? G avi 1�< p /�^^ C312.00# <br /> Property Owner's Mailing Address 7 0]gZ3 /1�j2(4�jQ'7"`'� <br /> (936. P lC e i e i/! J J Govt.Lot <br /> Property Location <br /> City,State Zip Code Phone Number <br /> 17 I <br /> 5� z -�j�.- /�f 5 r- 1/4.6r_% section 2 6 <br /> 7—/1'�5� circle one <br /> II.Type o Building(check all that apply) Lot# T N; R 1 E orb <br /> yI or 2 Family Dwelling—Number of Bedrooms 3 Subdivision Name <br /> Block# <br /> ❑Public/Commercial—Describe Use <br /> 0 City of <br /> ❑State Owned—Describe Use CSM Number 0 Village of�/� <br /> 14 Town of/� een47'/ <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) I <br /> A. <br /> New System 0 Replacement System 0 Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> B. 0 Permit Renewal 0 Permit Revision 0 Change of Plumber 0 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 /> ANon-Pressurized 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) <br /> 0 Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Des1$ Daw(gpd) I Design Soil A ation Rate(gpdsf) l Disperser q, R.uired(sf) Dispersal Arta Proposed LL//IIO� O`J�r p ( S stem Elevation <br /> - <br /> VI.Tank Info Capacity in Total #of ��r G. ��� <br /> Gallons Manufacturer <br /> Gallons Units as e <br /> 13 <br /> New Tanks Existing Tanks () /i u <br /> w 5 a <br /> Septic or Holding Tank ip�'0 )0ce i mi 1 p <br /> Dosing Chamber l 7�� <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Pl ber's Name ) Plumber's S. e <br /> _[_ '5-5c7 c / ) �MPQ/MPRS Number Business Phone Number <br /> Plumbers A dress(Street,City,State,ZipCode) -7;41-ivV 1072 7l <br /> tY 6?�-, 5- <br /> 1/'4 7QQ3 ( ,FeY <br /> VIII.County/Departme y my), L—C4 ke kcf -1 P/ I G1 <br /> Permit Fee/ Date Is ed Issuing Agent Signature <br /> ttApproved ❑Disapproved <br /> 0 Owner Given Reason for Denial 3 7J 7/2--s-A, <br /> IX.Condition <br /> s of ApprovaUReasons for Disapproval _ <br /> C—kAk 13 1ilLa <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 112 x 1 l c Fa..© E O V E <br /> SEP 2 5 2020 <br /> SBD-6398(R.08/14) <br /> Burnett County <br /> Land Services Department <br />