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County <br /> Industry Services Division BLA r n e <br /> 1400 E Washington Ave 5anifary Permit Number(to be filled in by Co.) <br /> ' - <br /> __-- P.O. Box 7162 - <br /> ' Madison, WI 53707-71 62 <br /> T i <br /> C 12q, b t�'�t 893 <br /> Sanitary Permit Applica.t.ion 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 POWfTS are submitted to Project Address(if different than mailing address) <br /> the Department of Safety and Professional Servies• Personal information you provide maybe used for secondary ) 7s— <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. <br /> I. Application Information—Please Print All Information A" aP 7do• <br /> Property Owner's Name Parcel# 4 0 -/y_ 6S- S 1 s,--S7t <br /> / 07-OAS,A- _ l��1 l7r7U <br /> 7hovn Sort <br /> Property Owner's Mailing Address Property Location q <br /> P rtY g dr TQ)( t b' : �q2o <br /> ,t 3 7 7f ti i­e J Govt.Lot <br /> City,State Zip Code Phone Number /, y,, Section <br /> N S.S 0 73 (circle one <br /> T y0 N; R /N Eo( <br /> 11.Type of Building(check all that apply) Lot# Q <br /> 0 1 or2 Family Dwelling—Number ofBedrooms � / Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> ❑State Owned—Describe Use CSNI Number p Village of <br /> ®Town of SLo74- <br /> IIh.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' ❑New SystemEEIRe, <br /> nt System p y Y p❑Treatment/Holding Tank Replacement ❑ Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner I NV <br /> IV.. "e,of POW T•S.S stem/Com onent/Device: (Check all that apply) <br /> Noii e Yid la-Ground ❑Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑C{alamTTiia ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> VSD s ei aI/Treatment Area Information: <br /> Desfgiito+i(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(st) Dispersal Area Pr�UE <br /> 3 v 7 <br /> VI.Tank Info Capacity in Total #of ManufacturerU <br /> Gallons Gallons Units 42 <br /> New Tanks Existing Tanks =w U P. <br /> Septic or Holding Tank �O G O /6 GO '/ �r/T J �Y�t 1fo✓ <br /> Dosing Chamber- j } <br /> VII.Responsibility.Statement-I,the undersigned,assume responsibility for installation of the POINTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> lc, s / ��.-.�./ �� �►J,r�S ��s= �G(r yes <br /> Plumber's Address(Street,City,State,Zip Code) <br /> ; 776,0 Ay 3,S w-v6,S-1r.- vvr- <br /> VilI.Coun /De artment Use Only <br /> Approved El Disapproved Permit Fez Date[ssue Issuing gent Signature _ <br /> ❑Owner Given Reason for Denial <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> me of au �a.cls C = Q a IFFoil� a ti, cotm+y old S f r�-I� ���u ir�:rr�err t5 <br /> mo►i� 1 <br /> Jt krmifU d � 4i 44 i✓t� c- (cUr,RCCL-�Oq� <br /> �'A�► <br /> Attach to complete plans for the system and submit to the County only on paper not less than 2 x I in s i e <br /> Burnett County <br /> Land Services Department <br /> 0o- <br /> ,,,. <br />