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Industry Services Division Co ty <br /> ?% -r <br /> - - 1400 E Washington Ave <br /> •s = P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> f� y: Madison WI 53707-7162 — 2`9 &01 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 38321(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.15.04(1Xm),Stats. <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name n Parcel <br /> /l VA .�,r P A , ,n C 7 `5 nc3 310e21 <br /> Property Owner's Mailing Address t,� p-_ p Property Location <br /> do/7 I.` /e >fic7�de •fit 4 Govt Lot C=Sm#CI3.Ps Y73P�'' <br /> City,State Zip Code Phone Number �' ' &' <br /> �Y � 6'4�<, s as 2 <br /> GIrem ltas rot 6- rb cucle one <br /> H.Type of Building eck all that apply) Lot f T [ N.; R E or( <br /> ®1 or 2 Family Dwelling-Number of Bedrooms l 1 Subdivision Name <br /> Block <br /> 0 Public/Commercial-Describe Use ❑ City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> 8'Town of <br /> � � I <br /> III.Type of Permit (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> ❑New System a 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 <br /> 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 ❑At-Grade ❑Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> Eff 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 it of Manufacturer <br /> Gallons Gallons Units <br /> New Tanks Frissing Tanks c y 'e. y , a <br /> J r ;n <br /> Septic or Holding Tank <br /> X � Lc.�.E'_�s ��nGlY°� <br /> Dosing Chamber <br /> . i <br /> VII.Responsibility Statement-I,the undersigned,assamc responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Pi lilt) Plumber' r I MP/MPRS Number Business Phone Number <br /> i'dbe- i. /354ss` i3'��s3-?sue <br /> Plumber's Address(Street,City,State,Zip Code) <br /> ‘3,5"72 //5' _c• ?^- /`�ct ,`c. - i <br /> V(III.County/Department Use Only <br /> Approved ❑Disapproved Permit Fee gDate Issued mg <br /> jAg Si <br /> ❑Owner Given Reason for Denial S 3 77 ( 1 J UN 1L " r' <br /> IL Conditions of Approv easons for Disapproval <br /> al( `e+ -1 /0q4c.ii 4r3-15 <br /> CC EOMC =\\ <br /> • <br /> Attach to complete plans for the system and submit to the County only on paper not less than 812 z I. in size <br /> SEP132022 .,j, <br /> Burnett County <br /> SBD-6398(It 08/14) Land Services Department <br />