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12� Industry Services Division County <br /> 1400 E Washington Ave u(MG <br /> P.O.Box 7162�si $ Sanitary permit N ber(to be filled in by Co.) <br /> Madison,WI53707-7162 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.2I(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit <br /> is required prior to obtaining a sanitary permit Note:Application forts for state-owned POWTS are submitted to Project Address(if different than mailing address) <br /> the Department of Safety and Professional Services.Personal inforrnation you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s.15.44(1)(m),Stats. <br /> I. Application Information-PIease Print All Information (Q( <br /> Property Owner's Name Parcel# <br /> A,J�t°� 67��6r1-39�1`-z� 03- -o�3mo <br /> Property Owner's Mailing Address property Location -r-uk l D l Z'S 9 <br /> Gout Lot / <br /> City,State Zip Code Phone Number �, , <br /> I 1 W /+, /, Section Z <br /> circle one <br /> T_5cl N, REO <br /> II.Type of Building(check all that apply) Lot# <br /> l or 2 Family Dsvolling-Number of Bedrooms Subdivision Name <br /> // Block <br /> ❑Public/Commercial-Describe Use ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of y/ / <br /> '/i n� 6 TO,,, /r of ezyo/y <br /> Ill.Type of Permit: (Check only one box on Une A. Complete line B If nppiilleable) <br /> A. <br /> ❑New System gRepiacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> $- ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Bate Issued <br /> Before Expiration Onner O 37F p 129 11 q-i y <br /> IV,Type of POWTS System/Component/Device: (Check all that a ,�,1/) <br /> ❑Non-Pressurized In-Ground ❑ t.,y i Pressurized In-Ground ❑At-Grade vlound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dis ersaYrreatment Area Information: <br /> Design Flow(gpd) I Design Soil Application Rate(gpdsf) Dispersal Area Required(st) Dispersal Area Proposed(sf) System Elevation <br /> VI.Tank Info Capacity in Total ff of Manufacturer <br /> Gallons Gallons Units ' o <br /> NcwTaaks Existing Tanks <br /> c,U y y rn ii t7 0. <br /> Septic or Holding Tank U r G <br /> Dosing Chamber <br /> VII.Responsibility Statement-1,the undersigned,assume r5Wousibillty for installation of the POWTS shown on the attached plans. <br /> Plu er's N�CE' <br /> (Print) Plumber's S' �� MP/MPRS Number Business Phone Number <br /> 1f4, � i <br /> Plumber's Address(Street,City,State,Zip Code) <br /> �bet Avokiv 1 A, ;go/ (Ajeb,�Ar <br /> VIII.Court /De artment Use Only <br /> Approved ❑Disapproved Permit Fee Date Issued Issuing Agent si7a <br /> s y2 SpD g 22 zaq <br /> ❑Owner Given Reason for Denial <br /> IX.Conditions of Approval/Reasons for Disapproval y <br /> � <br /> i(M {- W SP,-f'Iz s t 6o4 <br /> Attach to complete plans for the wstem and submit to the County only on paper not less than 8 1r2 s 11 <br /> Burnett County <br /> Land Services Department <br /> SBD-6398(R 08/14) <br />