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<br /> -e‘.01-511 ,11;;;•-\. County --..
<br /> Industry Services Division /3LA r 01 ,e-1,---
<br /> ,VIEr4:;':,..); ,, A.. 1400 E Washington Ave Sanitary Permit Number(to be tilled in by Co.)
<br /> ri P.O. Box 7162
<br /> 11/11--,..„?-3 -24.
<br /> Madison, WI 53707-7162
<br /> State Transaction Number
<br /> Sanitary Pei ant 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 ai-7 Li 4/
<br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats.
<br /> I. Application Information-Please Print MI Information L.i 0 Co th .5-1L
<br /> Property Owner's Name Parcel#
<br /> 0,cap-)- .1-/S---..1.5
<br /> ni c,IA C y (6 1,-/Soo
<br /> •
<br /> Property Owner's Mailing Address Property Location
<br /> 3 0 4/.0-7' r24 (cosi /Yve Govt.Lot
<br /> City,State Zip Code Phone Number ,A,
<br /> 1/4, Section .?4,1
<br /> -5-71-a c y in/I/ ri-67 q T e.,,0 N; P.
<br /> 1 eirclEe oon&
<br /> IL Type of Building(check all that apply) Lot#
<br /> M 1 or 2 Family Dwelling-Number of Bedrooms ) .$ Subdivision Name ,
<br /> Block#
<br /> 0 Public/Commercial-Describe Use
<br /> 0 City of •
<br /> •
<br /> CSM Number El Village of
<br /> 0 State Owned-Describe Use
<br /> V, j S- Pal IT 21 Town of 04 le-/411 el
<br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) '
<br /> A. 0 New System 0 Replacement System IN/Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain)
<br /> List Previous Permit Number and Date Issued
<br /> B. 0 Permit Renewal 0 Penmit Revision 0 Change of Plumber ii Permit Transfer to New
<br /> .,,-
<br /> Before Expiration Owner -
<br /> IV.Type of POWTS System/Component/Device: (Check all that apply)
<br /> g:T,a-s(3'.1i-iirt*-i Pressurized In Ground El Pressurized In Ground 0 At:Grade El Mound>24 in.of suitable soil 0 Mound<24 in.of suitable soil
<br /> i a',tfoldiiigaTaiik El Other Dispersal Component(explain) 0 Pretreatment Device(explain)
<br /> WIDIsiftWal/Treatment Area Information:
<br /> Des EgEFFIN((gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation
<br /> 3 a v 7 40 5" 9fa
<br /> VI.Tank Info Capacity in Total #of Manufacturer
<br /> Gallons Gallons Units
<br /> New Tanks Existing Tanks 48
<br /> ,, g .-.4-% E :12 ; r2. '• '• =2;
<br /> c.CJ c./) . ci) 4-.(7 1:1-,
<br /> _
<br /> Septic or Holding Tank / 0 1---,'/
<br /> Dosing Chamber- ' ) ').i
<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 /> /-?!GA A vs /a(114- d W • 01 2..S.-8.3-7 7/sz,5‘,6 -4/45-7
<br /> Plumber's Address(Stre t,City,State,Zip Code)
<br /> ,172 GO /4 4.-y 3..3-- (A.,-e 6 5 74-, tti-r--
<br /> VIII.CountyDepartment Use Only
<br /> NPermit Fee Date Issued eApproved 0 Disapproved CA' Issuin gent Si ature ,cE11,v 2---
<br /> t .1\
<br /> 0 Owner Given Reason for Denial ...--
<br /> 4--
<br /> IX.Conditions of A.vproval/Reasons for Disapproval
<br /> ork-
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<br /> Cade aff reo ca ?iela cir) 19e useg -fer;m:It ieflkct,4 t.. eiPi APR 2 8 2023
<br /> _....
<br /> 1-0tee4- 01 5e4-backs 4 5-44 ter,
<br /> Burnett County
<br /> Land _ Po Services De artment
<br /> Attach to complete plans for the system and submit to the County only an paper not less than 8 1/2 X 11 inches in size
<br /> 4 PrS-15`.?-1L's
<br /> c--),\ka *727q4-i
<br /> SBD-6398 (R0313)
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