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j "'° Industry Services Division County 4 <br /> Ix;. <br /> B `::`• 1400 E Washington Ave (Me- <br /> S ;_ P.O.Box 7162Sanitary Permit Number(to be filled in by Co.) <br /> 4 S .-' : Madison,WI 53707 7162 J—.II _332 (bLIp 6070 <br /> Ch1 ;!; Csi-.2t-2 L <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 <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 Services.Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s.15.114(I)(m),Stats. <br /> I. Application Information-Please Print All Information zif •y <br /> fere lk a <br /> Property Owner's Name 4e'Ah'v Parcel# \574.3 <br /> iv <br /> Property Owner's Mailing Address ' Property Location <br /> 68gD ffre.a,g�(/1/ Govt.Lot 2' <br /> City,State lLip Code Phone Number y,, '4, Section <br /> gi.10/#00 I'e (I: !,)546 (circle one) <br /> T N; R EorW <br /> H.Type of Building(check all that apply) Lot# <br /> tiri or 2 Family Dwelling-Number of Bedrooms Z-- Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> 0 City of <br /> ❑State Owned-Describe Use CSM Number 0 Village of <br /> V01 fZ/ Fil Town of KW?k <br /> Ill.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> 0 New System "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 /> ( Non-Pressurized In-Ground ❑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) 0 Pretreatment Device(explain) <br /> V.DispersaVTreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> .50 •7 yZ 7 7 qh•6 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units ' o <br /> New Tanks Existing Tanks U y <br /> a.U nn y v3iis: 3 a <br /> 75-0 <br /> ���yy�� <br /> Septic or Holding Tank r199 99 4, <br /> Avilei-( x <br /> Dosing Chamber 600 <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) Plumber's ,' re MP/MPRS Number Business Phone Number <br /> r , T llq � �� 86/952/ 76---S((-62o <br /> Plumber's Address(Street,City,State,Zip Code) l <br /> 6get Ai Ile 4/ �Je6 /•- Lit` 5111393 <br /> VIII.County/Department Use Only _ <br /> 0 Approved 0 Disapproved Perr�mitt Fee o9 Date Issued op •_A:i nt Sip% / <br /> ❑Owner Given Reason for Denial S-! mac.! 1 i I LII lik , , <br /> IX.Conditions of Approval/Reasons for Disapproval # //� <br /> tU(ti22,4 <br /> Attach to complete plans for the system and submit to the County only on paper not las than 81r=s t 1 i t c Isizc 1 - <br /> e <br /> SBD-6398(R.08/14) Burnett County <br /> Land Services Department <br />