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N <br /> '�•"' `'.-N, County <br /> .< -.-. ''°;:+ Industry Services Division �Vr e-{'-� <br /> LP',-�.." 1400 E Washington Ave <br /> 'mot Y'��''° � 9 Sanitary Permit Number(to be tilled in by Co.) <br /> P.O. Box 7162 t ).1 t — 1,5" u.�Q, <br /> i ';.:-: .rt, Madison, WI 53707-7162 <br /> chi- ��-4� _ <br /> State Transaction Number <br /> Sanitary Permit Application <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 Servies. Personal information you provide may be used for secondary 22-1544 t e q+-Fe 11 Po vt+ 1Z1 <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stets. <br /> I. Application Information—Please Print All Information _ <br /> Property Owner's Name Parcel# <br /> Sc ot-i- $ouu)e 5 07- 0rt-z-3g-lS 6 4-c o5-17 <br /> 027000 <br /> Property Owner's Mailing Address Property Location <br /> 710 I 1404.k "Terra( j�,e. r' Govt.Lot <br /> City,State Zip Code Phone Number ,A, 'A, t-{ <br /> -{ <br /> gain 4. VI/l N 55'-13 q 1 �J Z-2L-5(O5 7 circle one <br /> T 3 N; R i5- E orW <br /> II.Type of Building(check all that apply) Lot# <br /> �F or2 Family Dwelling—Number of Bedrooms Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use ❑ City of <br /> ❑State Owned—Describe Use CSM Number ❑ Village of J <br /> KTownof C caoIte e— <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> ❑ New System K Replacement System 0 Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> B• CIPermit 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 0 Pressurized In-Ground ❑ At Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑ Fioldtn=Tank ❑Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> V,Dispersal/Treatment Area Information: <br /> DesignFla*(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> •7 L-150 Ce'-{3 CQ5"O 4'5•0 <br /> VI.Tank Info Capacity in Total #of Manufacturer v <br /> Gallons Gallons Units a eu 0 , <br /> New Tanks Existing Tanks S a ' y m 2 <br /> 0 <br /> n.U m y co u.V C <br /> Septic or Holding Tank l D O a t G Kau-) X <br /> Dosing Chamber- . ) :)t <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> ��cLea'a ao Iy�-/ 27.5155 I TS-6 co -Y157 <br /> Plumber's Address(Street, ity,State,Zip Code) <br /> Z11 coo �w� 35 GOeb . tt 5 1'S <br /> VIII.County/Department Use Only <br /> Approved ❑ Disapproved Permit Fee zI25 51542 Date Issued ilia Ag t Signatur <br /> � <br /> ❑ Owner Given Reason for Denial - <br /> IX.Conditions of Approval/Reasons fo Disapproval <br /> Meth- all 4561494c , tr 9 • <br /> -11 L-4a';G° MAY 2 2022 0, <br /> __, <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 in s 11 in. h" in°"" <br /> Burnett Counter <br /> Land SerVicee Department <br /> SBD-6398(R0313) <br />