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a°Yxnar„ 'r Industry Services Division County <br /> „�` p.. 1400 E Washington Ave 2 N f a $ P.O.Box 7162 p5` Sanitary Permit Number(to be filled in by Co.) <br /> ��.. Madison,WI 53707-7162 11 ��(��42g,b <br /> iwowr•�f~ /y1 V - 1,3-_3, <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 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 <br /> u oses in accordance with the ,rivac Law s.15.04 1 m Stats. Allp <br /> J e � Z//D '7 <br /> I. A lication Information-Please Print All In <br /> t Miffry•Uwner's Name aformation yj /( lac, /�r <br /> £ J_ <br /> L � K i�S �-G�£s Panel# a ?a.3 y- L -3'1-/$-2 <br /> Property Owner's Mailing Address S S- y 9 d l /0 0 G <br /> Property Location <br /> jy�� ftiLd�,v (,lot' <br /> City,State ZipCode Govt.Lot <br /> Phone Number <br /> �j Y4, Y4, Section Z <br /> D J /Yr� <br /> if.Type of Banding(check all that apply) Lot# T 3� N; R j� E <br /> , 1 or 2 Family Dwelling-Number of Bedrooms 3 I j Subdivision Name <br /> Block# <br /> ❑P ublic/Commercial-Describe Use <br /> ❑City of <br /> fl State Owned-Describe Ilse C&M Nun,bol �0 Village-of <br /> ?,Town of I A-q <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A <br /> ems'System ❑Replacement System ❑Trestment/Holding Tank Replacement O <br /> r� ^ <br /> nly ❑Other Modification to Existing System(explain) <br /> JNon <br /> t�rernriricErrewdi t,reereniricevrsiorr •1,'nangC"OlYtumDer 't]2 e72dit lraft;IZs to i'lb T,ict Prrv�nne Permit Nnmlwraril T�tnrcenri <br /> Before Expiration Owner <br /> T e of POWTS S tem/Com onent/Device: Check all that a I-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑Mound_>24 in.of suitable soil ❑Mound<24 in.of suitable soiloing Tank ❑Other Dispersal Component(explain) <br /> Pretreatment Device(explain) <br /> V.Disnersal/Treatment Area Tnformatinn- <br /> Design si Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) D' - <br /> � rspersal Area Proposed(sf) System Elevation <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units d <br /> New Tanks Existing Tanks ° L) <br /> ZoUO J S/tf'a w <br /> Dosing or <br /> VIZ Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shoiyu on the attached plans. <br /> P ber's Name(Print) Plumber's Signature <br /> Number Business Phone� Number t�q + <br /> urnber's Address(Strut rity Ctatr. 7.in(nrlrl �Zz �?Z.. 7)J-//I �/{3F'j <br /> VIII.Coun /De artment Use Onl <br /> ,Approved ❑Disapproved Permit Fee Date Issued Issuin g Agemt Signature <br /> ❑Owner Given Reason for Denial $ 3 75 <br /> 7 <br /> �_ ��,, �8'•� � /,{�'��] <br /> JUL Conditions of Approval/Reasons for Disapproval <br /> D <br /> Attach to eomplete pleas for the system and submit to the Jron p Conn °ni a <br /> t9 per not Less rhea 8 ll2 x 11 i <br /> Burnett County <br /> SBD-6398(R.08/14) Land Services Department <br />