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f i �; Industry Services Division County <br /> %s; :t 1400 E Washington Ave tiCA. <br /> di- <br /> (;l S. P.O.Box 7162 <br /> p$ - ,` Sanitary Permit Number(to be filled in by Co.) <br /> vz'`' `w_ Madison,WI53707-7162 <br /> Q (/� <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(1)(m),Stats. <br /> I. Application Information-Please Print All Information 28?ZZ W W <br /> Property Owner's Name Parcel to 4 gi ens 07,47.0-z-v04.07.6- Af-6,41-ortacv <br /> Property Owner's Mailing Address <br /> zu <br /> r Property Location 114 3�2. <br /> ! 1 io '"/y� (i1 view �/y <br /> a z"J Govt.Lot <br /> City,State Zip Code Phone Number <br /> �+. ''/a, Section <br /> L Ci i17 4Ai 557Z3 <br /> - Tcircle one <br /> II.Type of Buil ng(check all that apply) 3 Lot Y T V N; R �� Ear <br /> [.I or 2 Family Dwelling-Number of Bedrooms /S Subdivision Name <br /> Block eve„ D4Kk <br /> ❑Public/Commercial-Describe Use <br /> 0 City of <br /> ❑State Owned-Describe Use CSM Number ❑V'llage of <br /> Town of t�Q(4I0.� <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> 0 New System 0 Replacement System R Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> B. 0 Permit Renewal 0 Pennit Revision 0 Change of Plumber List Previous Permit Number and Date Issued <br /> ❑Pemtit Transfer to New <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> or 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) <br /> 0 Pretreatment Device(explain) <br /> V.Dispersa))Treatment Area Information: <br /> Design afnnr(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> . 7 Oa l i�2 1 ?F,3 <br /> VI.Tank Info Capacity in Total #of l Manuthcturer <br /> Gallons Gallons Units = <br /> New Tanks Existing Tanks c U d <br /> E o Y. E u .c= e <br /> e U FA' vt i:. F., F.,Septic or Holding Tank /Ce�/�� / I S i <br /> Dosing Chamber fYO"QTI".vt x/ <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> PAdei <br /> lan cr's Name(Print)/ Plumber's Sigma �� MPIMPRS Number Business Pltone Number <br /> Plumh� ' � GiZ� 86 / 7/` - 'd <br /> r s Address(Street,City,State,Zip Code) �� <br /> 6 8( %� w L li ,4/ Uie6 L11' 509 VIII.County/Department Use Only <br /> Approved 0 Disapproved Permit Fee _gig_ Date Issued/ Is. 'ng g t Signa <br /> 0 Owner Given Reason for Denial S 375 .515t d? t/ •/ /�� <br /> IX.Conditions of Approval/Reasons for Di approval j <br /> ►�e�-- tI 5e -5 11.3o6 1 C C G M C 'l <br /> 315_ If MAY 2 2022 <br /> Attach to complete plans far the system and submit to the County only on paper not less than 8 I/2 s t 'It sire <br /> Burnett County <br /> Land Services Department <br /> SBD-6398(R.08114) <br />