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Industry Services Division County <br /> 1400 E Washington Ave guflydf <br /> ; ,•. ® <br /> P.O.Box 7162 2. Sanitary Permit Number(to be filled in by Co.) <br /> S Madison,WI 53707-7162 <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 trait <br /> is required prior to obtaining a sanitary permit.Note:Application forts 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 /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Slats. <br /> I. Application Information—Please Print All Information <br /> Property Owner's Name Parcel <br /> •5 , • or6--i -e Icy <br /> Property Owner's Mailing Address Property Location <br /> e 7/O olQl 3 ' Govt.Lot <br /> City,State Zip Code Phone Number y, '/4, Section <br /> w� 5_1q ft role one]^ <br /> II.Type of Building(check all that apply) Lot# T '` N; R 4 E or/f�u"/ <br /> *1 or 2 Family Dwelling—Number of Bedrooms Subdivision Name <br /> Block# �� <br /> ElPublic/Commercial—Describe Use ❑ City of <br /> ❑State Owned—Describe Use CSM Number ❑ Village of_ <br /> V Q 11172 ir Town of QQk N <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> ❑New System 5f Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B- ❑Permit Renewal ❑ Permit Revision ❑Change of Plumber List Previous Permit Number and Date Issued <br /> g ❑Permit Transfer to New <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: Check all that apply) <br /> L?Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑Mound>_24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑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 L o o ^ <br /> New Tanks Existing Tanks w = w y m <br /> a U in y y ii V ri, <br /> Scptic or Holding Tank Uu ter) <br /> A � <br /> Dosing Chamber _F <br /> �/W .Y <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for Installation of the POWTS shown on the attached plans. <br /> Plu cr's Name(Print) Plum naRtnC MP/MPRS Number Business Phone Number <br /> T llQ � //�.�-�/I r 9 S'z/ ors 10-626Z <br /> Plumber's Address(Street,City,State,Zip Code) <br /> G 8l A0 f Lk WW kle�b��- c„J� 2709 <br /> VIII.County/ e artment Use Only <br /> Approved ❑ Disapproved Permit Fee Date Issued i g Signa e <br /> ❑Owner Given Reason for Denial <br /> $ 37� -7• 1-2 -2-1 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> nD P k�� IE 9 Y [E <br /> Attach to complete plans for the system and submit to the County only on paper not less t l l Inches In size <br /> �, <br /> .�UL - 9 2021 <br /> � ata� <br /> SBD-6398(R.08/14) .1 0� Burnett County <br /> �t'q�6 Land Services Department <br />