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_ ,✓.,�. - County <br /> F7A <br /> ustry Services Division j�Lny�n�f� <br /> 9 sanitary Permit Number(to be tilled in by Co.} <br /> 00 E Washin ton Ave <br /> P.O. 13ox 7162 _ <br /> dison V�/I 53707-7162 <br /> n <br /> Sanitary Permit Application State Trasaction 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 P0WTS 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 01 741 f Cv <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. <br /> I. Application Information—Please Print All Information <br /> Property Owner's Name Parcel# <br /> ti'7 <br /> �Arr u arv'1 veii -S' ws—oflcoo <br /> Property Owner's Mailing Address Property Location lox U>: 141 L19 <br /> ll O S_ FL+ �� Govt.Lot <br /> City,State Zip Code Phone Number /, %, Section .3-7 <br /> S�i�f' W!ti ✓ N ��'� (circle one) <br /> Il.'I'ypeofBuilding(check all that apply) Lot# T `f� N; R�_Eor� <br /> l or Family Dwelling—Number of Bedrooms 0 Subdivision Name <br /> Block# <br /> ❑Public/Commercial—Describe Use Z El of <br /> ❑State Owned—Describe Use CSblNumber p Village of <br /> �Townof <br /> I13.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> ❑New System �Replacemeat System s p y P <br /> B. 0 Permit Renewal El -nit Revision ElChange of Plumber ElPermit Transfer to New List Previous Permit-7N mberand Date issued <br /> Before Expiration Owner 21 3 1 ! /Zms <br /> IV.:T"e,of POWTS.S stem/Com onent/Device: (Check all that apply) <br /> oa 1'�e surized ln-Grourid ❑Pressurized[a-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil. <br /> Eia(amyTarik ❑Other Dispersal Component(explain) ❑Pretreatment,Device(explain) <br /> VDs:ea]/Treatment Area Information: <br /> Des.irFfotiv(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevatio <br /> Sad I 1 4 1 boo (00 9) <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units ? u _ <br /> New Tanks Existing Tanks o <br /> c U m rn w U a <br /> Septic or Hold ng Tank I v G�J �O O / h r��/�✓a�v✓ ' <br /> Dosing Chamber_ ( F r 1 }� <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 /> �Zl c <br /> Plumber's Address(Street,City,State,Zip Code) <br /> (le µ, <br /> VIII. aun /Ije artment tse Only <br /> Permit Fee Dat [ssu d Issuing Agent Signaturz <br /> Approved El Disapproved 00 <br /> _ '/I n <br /> ElOwner Given Reason for Denial <br /> IX.Conditions of Approval/Reasons for;Disapproval D <br /> OW CW �4a� <br /> FtIlow A coady of �fJ Slak re?W� JUL 18 2024 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 112 s 11 i ches in size Burnett County <br /> Land Services Department <br /> Q <br />