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-4027;4i14- Coun <br /> a r „k. Industry Services Division %jtA,e h.G j`f <br /> Ye `, i , '�A. 1400 E Washington Ave Sanitary Permit Number to be tilled in by Co.) <br /> `.r.r.a. �,0 - rl P.O. Box 7162 rj'9}.N.� .- <br /> ��: ✓ <br /> ` ,,, Madison, WI 53707-7162 <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 60454 <br /> is required prior to obtaining a sanitary pennit. 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 7 Xi," <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. A I <br /> I. Application Information-Please Print All Information "t. 64,SS Li' Rai, <br /> Property Owner's Name Parcel# <br /> ,��-w►�s Ll.�c�s o7--c�r8=a-3g-I6 -17-1r'o _.000 <br /> o flood <br /> Property Owner's Mailing Address Property Location d 115,52 <br /> A 0/S ID, FI%iSp f7PJ Govt.Lot <br /> City,State Zip Code Phone Number y, /,, Section / <br /> (ter hiN <br /> circle one) <br /> P 5. S SiO�J. 5 N; R / Eor6 <br /> IL Type of Building(check all that apply) Lot# <br /> IX 1 or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> El City of <br /> CSM Number 0 Village of <br /> 1:i State Owned-Describe Use <br /> XI Town of /eeel6t7 <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.T i e of POWTS S stem/Com a onent/Device: (Check all that a a.1 <br /> 0;Nor Pressurized In-Ground ❑ Pressurized In-Ground ❑ At:Grade ❑ Mound>24 in.of suitable soil B Mound<24 in.of suitable soil <br /> 0_Holding Tank 0 Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V Dispers'l/Treatment Area Information: <br /> Design Ftii*(gpd) Design Soil Applicati n Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> 3 a o I.6 300 3Jti 99. 7/ <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> 12 Gallons Gallons Units t o , N . <br /> New Tanks Existing Tanks c0 <br /> E o 5 <br /> c,u � H ci.;-U a <br /> Septic or Holding Tank . ,, <br /> Dosing Chamber.. 6-B a S e% j . ., <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 Signatu MP/MPRS Number Business Phone Number 7 <br /> �?/ Cie— ,�/d/o,e, s /�/�,1- ),),i-g 7 list X46- yis <br /> Plumber's Address(Street,City,State,Zip Code) /_ \ <br /> )7 7 G 14-k y,5 14,-e-6s711-, b✓?- Sys'9', <br /> VIII.County/Deparment Use Only / <br /> Approved ❑ Disapproved Permit Fee Date sued -' a _ent Sign,ture/ / <br /> 0 Owner Given Reason for Denial $ ✓ � T 2t/Z026 / ' _` `_ <br /> IX.Conditions of Approval/Reasons for Disapproval � C C � �f� "464 `'�C E V E l-� <br /> vrogovo ail 6fait rtvw�' 6 Astece, ac 7 <br /> 4 C014.441t4, VIIDt PibW?A keel a ll 1.5$x+ ° <br /> � � JJL 2 8 2020 J <br /> of ixiS h �m. 4, ba Zam.doKeitd per SM. W. _ <br /> V Attach to complete plans for the system and submit to the County only on paper not less than 8 t/_s 1 inches in size I <br /> Burnett County <br /> Land� - Services Department <br /> SBD-6393(80313) el. '�C L808 <br />