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Industry Services Division County <br /> 1400 E Washington Ave (�/( <br /> P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> t,4 FS Madison,WI53707 7162 <br /> �h%a •a '— <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 38321(2),Wis.Adm.Code,submission of this form to the appropriate pveralaental 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),Stars. Z /?/ �le I. Application Information—PIease Print All Information K) <br /> Property Owner's Name Parcel# <br /> lrex,J ale 0 7vM <br /> Property Owner's Mailing Address Property Location—TV- 5 5 2 5 <br /> // / <br /> h a�i� Govt.Lott <br /> City,State Zip Code Phone Number % Y; section Z 19 <br /> kh�-A ru 55/2 le on <br /> II.Type of Building(check all that apply) Lot T �U N; R Eon; <br /> ❑1 or 2 Family Dwelling—Number of Bedrooms l Subdivision Name <br /> Block 9 <br /> ❑Public/Commercial—Describe Use <br /> ❑City of <br /> ❑State Owned—Describe Use CSM Number ❑Village of <br /> CjTotrzl of <br /> Ill.Type of Permit: (Check only one box on line A. Complete line 13 if applicable) <br /> A. New System <br /> y ❑ 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 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 /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dis ersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Proposed 10 System Elevation <br /> W . 7 l i M_ I <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> u <br /> Gallons Gallons Units o $ ,2 <br /> New Tanks Existing Tanks c v °u a <br /> C.U in M m iz t7 a. <br /> Septic or Holding Tank IRV ` <br /> Dosing Chamber <br /> V11.Responsibility Statement-1,the undersigned,assume responsibility for btstallation of the POWTS shown on the attached plans. <br /> Pi , or's ND/,R; <br /> (Print) Plumber's MP/MPRS Number Business Phone Number <br /> / �5l95 ,ram-s�-azo� <br /> Piumbrr's Address(Street,City,State,Zip Code) <br /> bet <br /> VIII.Coun /De artment Use Only <br /> A.Approved ❑Disapproved Perm/it�FCee Date Issued Issuing Agent Sigoantre <br /> ❑Owner Given Reason for Denial S I-r1Zq1ZZq <br /> I L Conditions of AppproovallReasons for Disapproval ,(� <br /> �0 6V alQ su1 ad Va4 rre�wle- 1.eil-1s PD �--� .- <br /> C <br /> Attach to complete plans for the system and submit to the County only on paper not less than 812 s 11 inches in.sim JUL <br /> Burnett County <br /> Land Services Department <br /> SBD-6398(R.08/14) (hy25 .f 12775 <br />