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,:r "..S Industry Services Division County <br /> :, 0 1400 E Washington Ave aV�e" <br /> i , .• re ; P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> . �: Madison,WI 53707 7162 5l�1J-22- 17�. <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. 15.04(I)(m),Stats. <br /> I. Application Information-Please Print All Information 2%7 31 /lZD retA l,'v <br /> Property Owner's Name Parcel# <br /> fila ve /nerpe J or-, -z-3B/4,4-5 as-exq-ozea, <br /> Property Owner's Mailing Address Property Location <br /> 1/Z6S AJ /CU(t/ Mt- S2 <br /> Govt.Lot <br /> City,State i i Zip Code Phone Number v.,. % /8 <br /> / , Section <br /> WW6lh� /� SS/Z ci2 p (circle one} <br /> II.Type of Buffeting apply) T /D N: R iit E oi✓wrJ/ <br /> YP g(check all that a ly ,l Lot# <br /> III or 2 Family Dwelling-Number of Bedrooms "7 Z-- Subdivision Name <br /> Block g <br /> ❑Public/Commercial-Describe Use <br /> 0 City of <br /> ❑State Owned-Describe Use CSNI Number 0 Village of <br /> CL� Y Z PZ 8 Town of 02 t l/G� <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> 0 New System CfReplacement System 0 Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> B. 0 Permit Renewal 0 Permit Revision ❑Chan a of PlumberList Previous Permit Number and Date Issued <br /> S 0 Permit Transfer to New <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> L?Non-Pressurized En-Ground 0 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.Dispersalareatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(si) Dispersal Area Proposed(sf) System Elevation <br /> 600 VV@QGG,, 857 i V8 6 9a/ <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units c-g <br /> New Tanks Existing Tanks a '- u u H <br /> c,V in a iz t.7 a. <br /> Septic or Holding Tank 56 ago <br /> A �CP +' �( X V <br /> Dosing Chamber Si()CC// /J f G �y� �( <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plu ecr's Name(Print) Plumbs' gnaturc /. MP/MPRS Number Business Phone Number <br /> 0* viviv / 76.- 56G-azoZ <br /> Plumber s Address(Street,/� City,��State,Zip Code) {� � f/,, ' / <br /> 658( /T i 7z,,4 z 4/ k)e r - W s- 5%59, <br /> VIII.County/Department Use Only <br /> Ve <br /> Approved 0 Disapproved Permit <br /> Fee od Date Issued Issuin A ens Sign <br /> 0 Owner Given Reason for Denial S`"I?'5—` 6/61?? C . <br /> IX.Conditions of Approval/Reasons ir Disapproval - <br /> © E 0 V E-Iiig'\,'D <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 tR x I Tze <br /> i. Alb 3 2022 <br /> SBD-6398(R.08/14) Burnett County <br /> Land Services Department <br />